5Th Common Review Mission- Chhattisgarh

2011

5th Common Review Mission- Chhattisgarh

Contents

1. Introduction……………………………………………………………………………….2

2. Chapter 1 (Team members and Facilities Visited)……………………………………….3

3. Chapter 2 (Introduction and Baseline of Public Health System in the State)…………….7

4. Chapter 3 (findings of the 5th CRM in the State)…………………………………………12

LLIN intervention Success Story…………………………………………………………30

Recommendations………………………………………………………………………...43

5. Chapter 4 (Note on ASHAs)……………………………………………………………...48

Key findings/ comments of community interaction, FGDs with ASHAs, AWW………..50

Annexure-I (District Profile Kanker)……………………………………………………..51

Annexure-II (District Profile Kawardha)………………………………………………....69

Introduction

The National Rural Health Mission (NRHM) was launched on 12th April 2005, to provide accessible, affordable and accountable quality health services to the remotest rural regions. The thrust of the Mission was on establishing a fully functional, community owned, decentralized health delivery system with inter sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health like water, sanitation, education, nutrition, social and gender equality. Institutional integration within the fragmented health sector was expected to provide a focus on outcomes.

5th Common Review Mission visit to the States is based on the mandate of review and concurrent evaluation of NRHM.

A Twelve member CRM 5 Team visited the State during 9th – 15h November 2011 with the following members:

1. Mr. Biswajit Das, Director, MoHFW 2. Dr. Prema Ramachandran, Director, NFI 3. Dr. R.S Sharma, Joint Director, NVBDCP 4. Dr Manoj Nesari, Joint Advisor, AYUSH 5. Mr Gautam Chakraborthy, Advisor, NHSRC 6. Ms Ashi Kohli Kathuria, Sr Nutrition Specialist, World Bank 7. Dr. B. S. Deewan,NIHFW 8. Ms. Ekta Saroha, Strategic info & Policy, USAID 9. Dr. S. V. Gitte, RD, Raipur, Chhattisgarh 10. Dr. Subha Sankar Das, Consultant (SHP) 11. Dr. Hemant K Sharma, Consultant, NRHM 12. Mr Moni Mohan Manna, NRHM FMG

The Team members (1,3,6,9,11,12) visited Kanker district and the rest members (2,4,5,7,8,10) visited Kawardha district during 9th – 15nd November 2011 after the state level briefing in Raipur on 9th November 2011.

Chapter – 1 5th Common Review Mission Time-bound quantifiable goals had been specified in the road maps as indicated in the State Programme Implementation Plan for strengthening the health infrastructure with appropriate linkages and financial allocations. The 5th Common Review Mission was undertaken to review the changes in strategies of Health delivery system, improvement in outreach and including quality of services against the stated goals, objectives, outcomes and time lines The Teams Kanker Kawardha Mr. N.K. Khaka, District Collector Mr Mukesh Bansal, District Collector Dr. R.N. Pandey, CMO Dr K K Mishra, Civil Surgeon 1. Mr Biswajit Das, Director, MoHFW 1. Dr Manoj Nesari, Joint Advisor, AYUSH 2. Dr. R.S Sharma, Joint Director, NVBDCP 2. Dr. B. S. Deewan,NIHFW 3. Dr Manoj Nesari, Joint Advisor, AYUSH 3. Dr. Prema Ramachandran, Director, NFI 4. Ms Ashi Kohli Kathuria, Sr Nutrition Specialist, 4. Mr Gautam Chakraborthy, Advisor, NHSRC World Bank 5. Ms. Ekta Saroha, Strategic info & Policy, 5. Dr. S Gitte, RD, Raipur, Chhattisgarh USAID 6. Dr. Hemant Sharma, Consultant, NRHM 8. Dr. Subha Sankar Das, Consultant (SHP) 7. Mr Mani Mohan Manna, NRHM FMG

Members from State/ District: Members from State/ District: 1. Mr B Ananda Babu, SS & MD NRHM, 1. Dr K R Sonwani, Deputy Director, NRHM Chhattisgarh 2. Mr Prakash Saheta, State Account officer 2. Mr. Urya Nag, State Program Manager 3. Dr J C Meshram, CMHO 3. Mr. Anand Sahu, State M&E Officer 4. Mr , Pravin Sharma, DPM Kawardha 4. Dr. Jai Prakash, SPO, NVBDCP 5. Dr Salil Mishra, District RCH officer 5. Dr. R N Pandey, CMHO, Kanker 6. Mr Prahlad Ghritlahare, District Data Officer 6. Mr Rajiv Singh, DPM Kanker 7. Dr. D K Ramteke, DMO Kanker

De- briefing in the State

Objectives of the Mission  Reduction in child and maternal mortality  Universal access to public services for food and nutrition, sanitation and hygiene and universal access to public health care services with emphasis on services addressing women‟s and children‟s health and universal immunization  Prevention and control of communicable including locally endemic diseases and non-communicable diseases.  Access to integrated comprehensive primary health care.  Population stabilization, gender disparity reduction and demographic balance.  Revitalize local health traditions & mainstream AYUSH.  Promotion of healthy life styles.

Facilities Visited by the Teams I. Kanker

Sl Name Address / Location Level (SC / PHC / Name of the Person in CHC/other) Charge 1 CMHO Office District HQ Kanker CMHO Dr. R.N. Pandey 2 District Hospital District HQ DH Dr. D.K. Ture Kanker 3 SHC Dawarkhar Block Naharpur SHC Smt. Surekha Darro 4 PHC Sarona Block Naharpur PHC Dr. S K Gupta 5 SHC Mussurputta Block Naharpur SHC Smt A. Sori 6 CHC Narharpur Block Naharpur CHC Dr. Prashant Kumar Singh 7 PHC Korer Block Bhanupratappur PHC Dr. Hemant Chandrakar 8 CHC Antgarh Block Antagarh CHC Dr. B K Ramteke 9 CHC Bhanupratappur CHC Bhanupratappur CHC Dr A K Dhruv 10 AWC Picchekatta Mullah, Block AWC ANM- Smt. A Thakur Bhanupratappur 11 CHC Dhanelikanhar CHC Bhanupratappur CHC Dr. P Nareti 12 Village Adar Para Mullah, Block Village Mr. Jagannath Singh VK Bhanupratappur 13 SHC Kurishtikur Block Dhanelikanhar SHC Smt. Nandini Jain 14 SHC Kanharpuri Block Dhanelikanhar SHC Smt Kusum Lata Jain 15 Village Baar Devri Block Dhanelikanhar Village Village 16 SHC Potgaon Block Dhanelikanhar SHC Smt Bhupesh Ramteke 17 SHC Kodagaon Block Dhanelikanhar SHC Smt Mani Sahu 18 SHC Talakurra Block Dhanelikanhar SHC Smt. Shishir Maravi 19 Village Kapsi Block Dhanelikanhar Village Village 20 SHC Udkuda Block Charama SHC Ku Bharti Kujum 21 Village Gotitola Block Charama Village Village 22 Village Piprod Block Charama Village Village 23 PHC Haradula Block Charama PHC Dr O P Shankhwar

24 CHC Charama Block Charama CHC Dr J L Ulke

II. Kawardha :

Sl Name Address / Location Level (SC / PHC / Name of the Person in CHC/other) Charge

1 CMHO Office District HQ Kawardha CMHO Dr. J.C. Meshram

2 District Hospital District HQ Kawardha DH Dr K K Mishra, Civil Kawardha Surgeon 3 S.Lohara, Block S.Lohara, CHC Dr A.K. Thakur(BMO) 4 Pandariya, Block Pandariya CHC Dr P.L. Kurre(BMO) 5 Bodla Block Bodla CHC Dr S. Kohade(BMO) 6 Bhimbhori Block S.Lohara PHC Dr Sontosh Luniya(Attached at DH) Ramgopal Yadu (RMA) Shri Ashok Dahariya (pharmasist) 7 Pondi Block Bodla PHC Ku. Pooja Keshrwani (RMA) 8 Dullapur Block Pandariya PHC Dr S.K. Bandhekar 9 Kukdoor Block Pandariya PHC Dr B. L. Raj 10 Chilfi Block Bodla PHC Rakesh Rathore (RMA) 11 Pori Block Bodla PHC Ku. Pooja keshwarni, (RMA) 12 Daniyakhurd Block S.Lohara SC Smt. Dharmin Mehara(ANM) 13 Chilfi Block Bodla SC 1.Ku.Dhan Bai Dahariya(ANM) 2. Mr D.K. Berwanshi (MPW) 14 Oriya Kala Block S.Lohara SC Smt. Laxmi Gupta(ANM) 15 Visheshra (Parshwara Block Pandariya SC Smt. Nisha Sharma (ANM) SC) 16 Singhampuri Block S.Lohara SC Smt. K. Das (ANM) 17 Vishehara Block Pandariya Anganwadi (VHND) Smt. Sulochani Rajput

18 Daniyakhurd Block S.Lohara Anganwadi (VHND) Smt. Chandra Kumari Patel

19 Chilfi Block Bodla Anganwadi (VHND) Smt Asha Bai Dharvia(AWW) 20 Behsin Jhori Block S.Lohara Anganwadi (VHND) Savita Chhatari (ANM) [Bamhantola (SC)] 2.Urmila Sahu( AWW) 3. Maya Tiwari( AWW) 21 Pipartola Block S.Lohara[Mahartola Anganwadi (VHND) 1.Subhadra Chandrakar (SC)] (ANM) 2.Smt. Bisani sahu (AWW)

22 Surjapura, Block S.Lohara Ayurvedic Dispensary Dr. Sudesh Tiwari

23 Chilfi Block Bodla Ayurvedic Dispensary Chitranjan Das Bariha 24 Dullapur Block Pandariya AYUSH Gram Dr S K Sarnakar 25 Govt Primary School, Block Bodla Govt School Mr. Shiv Ram Jhariya Chilfi , 26 Govt Primary School Block Pandariya Govt School Ramanuj Sharma, HM Bisesera 27 Goraj Children Kawardha(Urban) Private hospital Dr. Govardhan Singh Hospital Private Thakur hospital Accredited under RSBY

Chapter – 2

Introduction:

Chhattisgarh:

The Profile – State:

Geography

Chhattisgarh is one of the few landlocked states of the country. Uttar Pradesh and Bihar bind the State in north, in the east it is bound by Orissa, in the south by Andhra Pradesh and in the west by Madhya Pradesh and Maharashtra. A large part of the state comes under Vindhyachal range that divides the Indian subcontinent into two. Mahanadi and Narmada are the principal rivers of the state. Narmada has its origin in Amarkantak, which lies in Chhattisgarh.

History

Chhattisgarh carved out of Madhya Pradesh came into being on 1st November 2000 as the 26th State of the Union. It fulfills the long-cherished demand of the tribal people. In ancient times the region was known as Dakshin-Kausal. This finds mention in Ramayana and Mahabharata also. Between the sixth and twelfth centuries Sarabhpurias, Panduvanshi, Somvanshi, Kalchuri, and Nagvanshi rulers dominated this region. Kalchuris ruled in Chhattisgarh from 980 to 1791 AD. With the advent of Britishers in 1854 Raipur gained prominence instead of capital Ratnapur. In 1904 Sambalpur was transferred to Orissa and estates of Sarguja were transferred from Bengal to Chhattisgarh.

The state of Chhattisgarh has an area of 1, 35,191 sq. km. and a population of 25.5 million. There are 18 districts, 146 blocks, and 20308 villages. The State has population density of 154 per sq. km. (as against the national average of 312).

The decadal growth rate of the state is NA (against 21.54% for the country) and the population of the state is growing at a slower rate than the national rate.

Situation analysis in beginning: The Indian state of Chhattisgarh was created on November 1, 2000. Carved out of the state of Madhya Pradesh, the new state, the 9th largest in the country with 24 million people, faced enormous socio-economic and development challenges- ranging from low literacy rates; low population density and geographically scattered communities; lack of basic public infrastructure; a population made up of roughly 1/3 tribal peoples; and a history of left-wing extremism and Naxalite conflict. Of the state‟s 18 districts, 12 have been classified as remote, tribal and extremist-affected areas. Public health indicators were particularly dismal. In 2001, the rural Infant Mortality Rate (IMR) in Chhattisgarh was the second worst in the country, at 95 deaths per 1000 live births (national average rural IMR was 74 per 1000). The percentage of underweight children was 61%. Maternal mortality rates and under-5 child mortality rates were very high. The state had the second highest prevalence of malaria in India. Physical infrastructure and other supply-side gaps compounded the problem. As compared to national norms, the state was short by 9 district hospitals, over 30 community health centers, and more than 200 primary health centers. The human resources gap was also staggering. Over 60% of sanctioned posts for doctors were vacant in 2001. At primary health centers, only 516 out of 1455 sanctioned posts for medical officers were filled. Doctors and other medical personnel simply did not want to serve in rural, impoverished, and conflict-affected areas. Demand-side issues also contributed to the state‟s poor public health indicators. Even where facilities existed, health care utilization was poor due to inadequate health education and awareness. Health-seeking behavior was often poor: there was an inappropriate reliance on traditional healers and „quacks‟; there was poor community participation and distrust of public health interventions; and some local traditions and customs perpetuated harmful patterns of child rearing and harmful health-related behaviors.

HEALTH INDICATORS OF CHHATTISGARH

State Profile:

Rural Population (In lakhs) Census 2011 196.04 Number of Districts (RHS 2010) 18 Number of Sub Division/ Talukas 96 Number of Blocks 146 Number of Villages (RHS 2010) 20308 Number of District Hospitals 17 Number of Community Health Centres (RHS 2010) 143 Number of Primary Health Centres (RHS 2010) 716 Number of Sub Centres (RHS 2010) 4776

Status of Health Indicators

Sl. NO Indicators Chhattisgarh India

1 IMR (SRS- 2009) 54 50 2 IMR (AHS, 2010-11) 53 3 MMR (SRS 2007-09) 269 212 4 MMR (AHS, 2010-11) 275 5 Total Fertility Rate (SRS- 2009) 3 2.6 6 Institutional Deliveries (In Lakhs) 2011-12 (Upto June) (MIS) 0.63 32.98 7 Full immunization (In thousands) 2011-12 (Upto June) (MIS) 133 4651

Demographic Profile

Indicator Chhattisgarh India Total population (Census 2011) (In crore) 2.55 121.01 Decadal Growth (Census 2011) (%) 22.59 17.64 Crude Birth Rate (SRS 2009) 25.7 22.5 Crude Death Rate (SRS 2009) 8.1 7.3

Natural Growth Rate (SRS 2009) 17.6 15.2 Sex Ratio (Census 2011) 991 940

Child Sex Ratio (Census 2011) 964 914 Schedule Caste population (in crore) 0.24 16.6 Schedule Tribe population (in crore) 0.66 8.4 Total Literacy Rate (Census 2011) (%) 71.04 74.04 Male Literacy Rate (Census 2011) (%) 81.45 82.14 Female Literacy Rate (Census 2011) (%) 60.59 65.46

Progress of NRHM

Sl. No Activity Status 1 24x7 PHCs Out of 716 only 67 PHCs are functioning on 24x7 basis

2 Functioning as FRUs 17 DH, 2 SDH and 39 CHC are working as FRUs.

In all 60092 were Selected and trained upto 5th Module, 44219 3 ASHAs Selected ASHA trained upto 6th Module and 43200 ASHA trained in 7th Module.

4 ANMs at SCs Out of 4776 SCs, 348 are functional with 2nd ANM.

325 AYUSH Doctors, 437 Staff Nurses & 437 ANMs are 5 Contractual appointments positioned under NRHM. 923 facilities (17 DH, 148 CHCs, and 741 PHCs & 17 Other 6 Rogi Kalyan Samiti Health facilities above SC) have been registered with RKS. Village Health Sanitation & 7 Nutrition Committees Out of 20308 villages, 19088 villages Constituted VHSNCs. (VHSNCs)

Physical Progress of Institutional Deliveries and JSY

Year No. of Institutional Deliveries (In No. of beneficiaries of JSY (In Lakhs) Lakhs) 2005-06 1.03 0.03 2006-07 1.31 0.76 2007-08 1.49 1.76 2008-09 1.79 2.25

2009-10 2.51 2.49 2010-11 3.25 3.76

2011-12 (Upto 0.63 0.64 June )

Services

Services 06-07 07-08 08-09 09-10 10-11 11-12

Male Sterilisation 6322 9922 10562 10078 7213 316

Female sterilisation 126772 143916 136604 136761 136855 3877

Full immunisation 586 569 571 627 133 (In thousands)(MIS)

Reproductive and Child Health Programme (RCH) in the State of Chhattisgarh a) Immunization Coverage

(Figure in percentage) NFHS-2 NFHS-3 Coverage Evaluation Survey

Year 1998-99 2005-06 2005 2006 2009 Fully Immunized 21.8 48.7 44.4 57.3 57.3 BCG 74.3 84.6 89.2 96.1 84.8

OPV 3 57.1 85.1 49.2 63.3 66.5

DPT 3 40.9 62.8 65.5 65.2 66.5

Measles 40.0 62.5 72.0 78.4 73.1

b) Information on selected MCH indicators

Indicators DLHS -2 (2002-04) DLHS-3 (2007-08)

Child feeding practices (%) Children under 3 years breastfed 29.5 50.1 within one hour of birth Children age 0-5 months NA 78.3 exclusively breastfed Children age 6-35 months exclusively breastfed for at least 6 36.6 43.3 months Children age 6-9 months receiving solid/semi-solid food NA 56.8 and breast milk

Awareness about Diarrhoea and ARI Women aware about danger 38. 1 47.1 signs of ARI (%) Treatment of childhood diseases Children with diarrhoea in the last 2 weeks who received ORS 41.7 36.6 (%) Children with diarrhoea in the last 2 weeks who were given 69.3 67.0 treatment (%)

Children with acute respiratory infection of fever in last 2 weeks 63.3 68.1 who were given advise or treatment (%)

Funds Released for total NRHM (In Crores) Year Allocation Release Expenditure# 2005-06 119.22 94.13 107.37 2006-07 174.21 149.11 187.69 2007-08 222.60 190.85 197.77 2008-09 259.35 249.72 162.12 2009-10 292.01 261.65 240.41*

2010-11 345.76 327.24 307.92*

2011-12 (Upto 392.54 133.64 28.92* June) Total 1805.69 1406.33 1232.20 *Allocation and Release figures are excluding kind grants. *Expenditure figures for 2009-10, 2010-11 and 2011-12 are Provisional. # Expenditure is more than Release due to previous unspent balance and includes state share.

Chapter – 3

Findings of the 5th CRM:

Change in key aspects of Health delivery system Item Observations 1. Infrastructure Development

Number of Facilities As on As on 31.03.2011 functioning in the State 01.04.2005

Total No of Total No of Functioning as per Facilities Facilities IPHS DH 16 17 0 CHC 116 148 0 PHC 513 741 0 Sub centre 3818 5076 0

Infrastructure development and maintenance is being done through PWD only. Infrastructure development is satisfactory but building construction is delayed and pace of construction is lagging behind time schedules. Quality of Construction is an issue as even some of buildings have developed visible cracks in walls even before commissioning (CHC- Dhaneli Kanhar, Kanker, District Hospital, Kanker, District hospital Kawardha also had seepage problems). No review is being carried out at any level. There is no coordination between PWD and District health society. Coordination amongst NRHM and other sources of funding like EUSPP, BRGF etc regarding Infrastructure development was not found. 2 newly commissioned SHC buildings were found side by side (Kanharpuri, Kanker) Residential accommodation is also deficient in the State but wherever accommodation has been provided, it is being utilized. All SHCs don‟t have provisions of water supply. PHCs and higher facilities have good facilities regarding connectivity (telephones and internet connection). In Kawardha many of these facilities are found non functional. In Kukdur PHC the delivery room did not have a toilet facility attached with the room. Labour rooms in all facilities in the pandariya block visited bears a non-use look except the CHC and DH.

In the CHC Pandariya a generator set was found functional just outside the patient ward within the facility building. In Kukdur PHC a solar panel enabled backup system was found to be installing while talking to the installation in-charge it was revealed that they do not know which rooms were to be connected with the backup system.

Infrastructure Progress: Facility No. of New No. of New No. of No. of buildings building Ongoing Works buildings with Completed in Occupied and Quality NRHM period used certification SC 1173 1165 1430 0 PHC 117 117 188 0 CHC 94 94 11 4

DH 7 7 1 5 Source: State Health Society

1383 Buildings have been occupied out of 1391 Constructed during NRHM period. Work is Still ongoing for 1630 Buildings.

Execution of infrastructure development and maintenance works in the State: 80% of infrastructure work is being done by PWD. Infrastructure sanctioned from NRHM can be done through private agency for the completion of planned construction work within the time frame.

For setting priorities for taking up construction/renovation works, Infrastructure wing of Chhattisgarh Medical Services Corporation (CGMSC) is under recruitment process. Infrastructure wing of CGMSC will handle all construction and renovations for better management.

Infrastructure As on 01.04.2005 As on 31.03.2011 Blood Storage Units 0 18 /39 Blood Banks 9 14 /17 SNCUs 0 1/9 NBSU 0 15 NBCC 0 48 Total Number of Beds 8734 12326 Bed population Ratio (No. of beds per 0.41 0.48 thousand population) Source: State Health Society

Residential Facilities for Staff : Facility Availability and Shortage of Staff Quarters at all facilities Type Doctors/ Specialists Nurses and Paramedics Other staff Required Available Required Available Required Available (Sept (Sept (Sept (Sept (Sept (Sept 2011) 2011) 2011) 2011) 2011) 2011) District 595 (43+28) 340 85 85 53 Hospitals 71 CHCs 888 (157 1480 (502+278) 444 262 +152) =780 309 PHCs 741 (37 +228) 1482 (464+228) 741 98 265 692 Sub- - - - - 10152 (1527+50 Centres 0) 2027 Total 2224 645 3302 1557 11422 2440 Source: State Health Society

There is Shortage of residential facilities across all levels (DH,CHC, PHC, SHC) for hospital staff throughout the State. Only 27% of the required residential facilities is present

in the State.

Duplication of facilities needs to be avoided as in district Kanker team found several facilities located side by side (Block Antagarh- SHC building beside CHC building, Block Charama- SHC building beside PHC Haradula, Block Bhanupratappur- SHC building beside PHC Korer)

SHC building under construction Staff Residential facility at PHC besides PHC building: PHC Korer, Korer, Kanker Kanker

2. Health Human Resources

HR status Required Sanctioned In position Gap Regular Contractual Doctors 2365 2365 1014 158 1193 (Allopathic) AYUSH 1092 1092 759 325 8 doctors Specialists 928 928 245 0 683 Paramedics 6092 3985 312 1795 5000 935 866 400 3734 Staff Nurses (NRHM) LHV 1084 1034 749 0 335 Pharmacists 1100 1100 733 0 367 1287 Rural Medical Assistant working in CHCs and PHCs

There is acute shortage of Health Human Resource in the State at all levels. 74% of the posts of Specialists and 50% of posts of MOs, 74 % posts of Staff Nurses are vacant however there is adaquate availability of AYUSH doctors. Efforts have been made from State to rationalise the existing Human Resource at appropriate levels. In view of severe shortage of Medical Officers in the State, it envisages to post all Medical officers at CHC level. PHCs are being strengthened with the help of Rural Medical Assistants (RMA) and AYUSH medical officers under supervision of Medical Officers at CHCs.

HR status Required Sanctioned In position Gap Regular Contractual MPW (Male) 5076 4918 2531 0 2545 ANM 5526 5526 4618 300 608 Lab Technician 1200 761 375 112 713 AYUSH 293 693 693 400 - Paramedics Cleaning Staff 5000 2914 2547 - 2453 ASHA 10 2920 2920 0 2910 Facilitators ASHA Co- 29 339 339 0 310 ordinators

MPW(M) are not present in all Sub- health Centres and 50% of posts are still vacant in the State. Availability of ANMs, ASHA Facilitators and ASHA Co-ordinators is good in the State. Sanctioned posts of Support Staff like cleaning Staff and Lab- technicians needs to be increased as per the requirements of the State.

In view of severe shortage of Medical Officers across the State and long recruitment procedures by State Public service Commission, efforts have been made to improve recruitment procedures, since April 2011 recruitment for doctors has been made open all time and a committee has been made which will review applications received and recruit doctors on quarterly basis (56 appointments have been made in the State)

To provide improved & efficient health services in the difficult and remote rural areas of the State Chhattisgarh Rural Medical Corps (CRMC) has been constituted in the State under which Monetary and other incentives (life insurance coverage, Marks for PG examinations- 10% of marks for each year of service up to maximum of 30%, Facilitation of spouse posting in the same areas/institutions, Choice of Posting after three years working in difficult and most difficult areas etc.) are being given to motivate and retain Human Resource working in categorically differentiated Difficult, Most difficult and Inaccessible areas.

The state is adopting the strategy of deploying RMAs in PHCs and relocating MOs to CHCs. There is need for capacity building of RMAs in program management and clinical care.

Pre Service Training Capacity: Facility 2007-08 Current Status Govt. Pvt. Total Seats Govt. Pvt. Total Seats SIHFW 1 0 1 NA 1 0 1 NA HFW-TC 1 0 1 NA 1 0 1 NA Dist.TC 6 0 6 NA 14 0 14 NA B.Sc. Nursing 1 10 11 450 6 41 47 2220 GNM-TC 4 2 6 161 4 25 29 981 ANM-TC 7 1 8 320 13 57 70 2404 MPW(Male) 3 0 3 180 3 41 44 2450 TC

Pre Service Training Capacity of the State has increased significantly over a span of 3-4 years. There is around Four fold rise in B. Sc Nursing and GNM-TC and around 9- 10 fold rise in ANM- TC and MPW(M) Training centres. There is slight contribution of Govt. sector as almost 90% of this increase in Training Capacity is contributed by private sector. The quality of education in these institutions needs to be ensured owing to severe shortage of faculty for a better outcome. There are no initiatives for Capacity building of existing faculty.

Short Course on health management were also proposed and approved in PIP for FY 2011-12. But only 6 Medical officers completed public health training.

There is severe shortage of faculty in the existing training. In Kanker 1 MPW(M) training center with 30 seats is being managed by block medical officer only along with his other responsibilities of the block. 1 ANMTC is having only 2 Faculty Staff- Principal and warden for 30 students. No training facilities (ANMTC and MPWTC) is reported in district kawardha.

Plan for Augmentation of Health Human Resources: For Augmentation of Health Human Resource in the State, State Govt. is increasing the no. of nursing colleges and ANM schools. Appointment of Nurses and ANMs have been increased. Career progression pathway for Mitanins and ANMs has also been devised through training of Mitanins to ANMs, ANMs to Nurse, and Nurse to Teaching faculty of Nursing schools.

Skills in Available Health Human Resources: Training requirement is developed but there are no training calendars. There is no integrated training calendar. There are individual nodal officers for trainings; No consultation is being done with SIHFW for organizing trainings in the State.

31 specialists have been relocated after training for utilization of Skills and rational deployment. To full fill the need of specialist doctors 32 EMOC and 15 LSAS has been trained. 15 EMOS and 10 LSAS are under training.

The team was able to examine quite a few personnel on a mix of skills during the visit. The ANM are generally well trained and are trained to collect malaria slide and finger prick blood for Hb estimation. The quality of slides they make is wanting and may allow more of false negatives. The lab technicians are good at their work but are used to take short cuts like making the thick smear and not making thin smear at all. Skills at all level for use of RDK was good.

B. P examination: SHC B. P examination, CHC Mussurputta, Kanker Antagarh, Kanker

The physicians were not very clear about management of undernourished children –both modern medicine and AYUSH. Some physicians have their own perception on management of malaria cases and that in pregnant women, which is different from NVBDCP guidelines. Clear protocols for management of malaria were lacking.

The Skilled Birth Attendant Skills (knowledge component) are of good order in ANMs and some of them are regularly using that skill for attended delivery at home.

ASHAs (Mitanins) have role clarity and are quite efficient in reaching the community, accompanying the mothers for delivery and in skilled jobs also they are doing well. ASHAs in the districts have some grievances regarding total earnings or timeliness of payments which is very less and irregular.

Mitanin demonstrating use of RDK test for malaria, SHC

RDK for malaria, PHC Dawarkhar, Kanker Sarona, Kanker

3. Health Care Service Delivery- Facility Based- Quantity and Quality

Total Annual Percentage Total annual In- Percentage OPD in the increase of OPD Patient increase of State over previous admissions in the IPD over year State previous year 2005-06 3474275 2006-07 3512450 1.09 380572 2007-08 3540512 0.79 402287 5.71 2008-09 3612219 1.99 426890 6.12 2009-10 3762565 4 443394 3.87 2010-11 4305814 12.62 459036 3.53

The OPD and IPD attendances in the State of Chhattisgarh are showing better utilization by the care seekers.

Total Annual OPD in the State Total Increasing OPD attendance 5000000 Annua over the Years - OPD was l OPD 4000000 relatively constant over a in the period of last 4-5 years. OPD 3000000 State in year 2010-11 shows an 2000000 Poly. increase of 12.62 % compared 1000000 (Total to FY 2009-10 Annua 0 l OPD in the State )

Total annual In-Patient admissions in the State Total annual 500000 In-Patient 400000 admissions in 300000 the State 200000 Poly. (Total Increased IPD utilization by 100000 annual In-

0 Patient care seekers- IPD shows an

admissions in upward trend over a period

07 08 09 10 11

- - - -

- the State ) of last 5 years.

2007 2008 2009 2010 2006

Service Delivery District Kawardha:

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 OPD 1,10,841 1,86,053 2,49,375 1,43,352 1,37,519 1,63,243 IPD 5,266 5,077 9,593 9,915 8,859 7,140 Increase over previous year OPD --- 67.86% 34.03% -42.52% -4.07% 18.71% IPD --- -3.59% 88.95% 3.36% -10.65% -19.40%

In Kawardha, over last 6 years there is 47% increase in OPD and 36% increase in IPD, but the increase in not continuous. There is Increase in institutional deliveries, including in SHCs. Bed occupancy of DH is 15-20%. There is a trust deficit in the community towards public health system due to sub-optimal functioning of DH (no Caesarean and no major surgery done in DH since last one year).

In Sub Health Centres (Kawardha) - All SHC visited had their own building excepting 1 all had access to water & toilet. Essential equipment such as anthropometric rods (non functional), weighing machine (inaccurate), Sahli‟s Hemoglobinometer (with reagents), BP apparatus (fully functional) needed for ANC were available. Registers were available and complete except in 1 place. However, the information did not appear to be reliable. It was recorded that 80% women were not anaemic, majority had body weight between 40-50kgs, and everyone had normal BP, and all babies weighted between 2.5-3.5kgs

PHCs and CHCs (Kawardha) - The essential weighing machines and height measurement rods were not functional or inaccurate. Functional gaps indicated above for SC also existed in PHCs. Cold chain equipments like deep freezer and ILR are there in functional condition but temperature monitoring and vaccine input-output were haphazard in some PHCs. There is no proper assessment of requirements of drugs and appropriate utilization of drugs provided by the state. None of the functionaries In the facilities visited had the knowledge of biomedical waste segregation, disinfection/decontamination, and disposal. Cleanliness was reasonably good in many facilities. Asepsis was suboptimal, and fumigation was patchy.

As a whole, the case load in the public health facilities is increasing over the years. Increasing trends are being observed for better utilization of the services provided at the health facilities. Institutional deliveries are happening in the sub-district facilities, thus the load on the district hospitals is reduced. Quality and follow up of the ANC is questionable.

Majority of the health facilities are having functional laboratories and are doing routine tests, e.g. Hb% estimation, Blood routine tests (TC, DC, ESR), Urine RE, Urine for sugar, albumin, etc. Pregnancy Test is being done by using „Nischay‟ kit, supplied by HLFPPT. Laboratory services in the public health facilities need some strengthening in terms of relocations of manpower, training, procurement, etc. Records in the Pondi PHC ANM revealed that the fetal heart beat is at constant 140 over registered ANC mothers. All ANC records however found to be all normal. None of the mothers were found to be anemic and none of the babies were reported under weight. However the accredited facility visited reported that most of the babies in the SNCU almost all of the inpatient were admitted with severe low birth weight. 30 % brought were reported with asphyxia. The survival rate of 30 % of the new born in such cases was reported. Of the 9 reported maternal deaths in (May to July, 11) of the block, 4 cases were reported because of excessive bleeding and anemia as cause of deaths. Of the 21 infant mortality dates of the same period 11 were reported of under nourished or under developed.

1. In Kawardha most of the delivery points in Pandariya block (PHC, CHC) visited did not have infrastructural facilities under IPHS for institutional delivery. Labour rooms were devoid of curtains, unused (PHC Pori, Bodla) or inaccessible (PHC Kukdur PHC) unclean (Pandariya CHC) toilets. 2. Succession pumps were found non functional in the PHC Pori and Kukdur PHCs 3. Medical waste management and infection prevention practices in all facilities including DH kawardha were found nonexistent including segregated collection. The 108 van at the DH were reported handing over their waste to the hospital. Medical waste was found scattered in open in the facilities The RSBY accredited private facilities were also found to be not maintaining any waste management protocols. This was neither a point for accreditation not is being followed up periodically. 4. Partographs of in patients were not found in any of these facilities to be maintained even when the SBA training protocols included sessions and format. 5. A general lack of awareness towards quality issues was observed among staff across the board from district to PHC level. Primary reasons for this was: lack of Technical/operational Guidelines: While the district officers along with the Medical Officers in charge of facilities are required to operationalize the facilities – Technical/operational guidelines particularly for IMEP are not available in the district. Standard/treatment protocols were not found in any of the health facilities

visited. 6. Except in the DH(1) and in CHC (1) no inpatients were found for institutional deliveries. Five deliveries were reported in the Kukdur in Oct 11 and only one in September, 11 in kukdur PHC. 7. Vaccine and logistics management and storing practices were poor, no proper indenting mechanism observed at facilities visited In the Immunization record and counting of Measles diluents and vaccine vial counts did not match (Kukdur and Pondi PHCs), BCG vaccines were reported out of stock. At Kukdur PHC vaccine indenting was not done and it is not known how many vaccines were received and their expiry dates. No proper recording and reporting of vaccines and logistics; no standardized formats for maintaining vaccine distribution and stock registers available

Ancillary services (diet, laundry) are not being provided regularly in all facilities across the State.

Travel and transport assistance is being provided to the seekers but referrals are very less due to unawareness of common public. Referrals are being done through mahatari express for pregnant women. But log books of these ambulances were not shared with the team.

The hospitals and health centers are clean and utilize NRHM funds for up keeping the same. Drugs are available now, though there was evidence of gross irregularity in supply in the recent past. The IFAs are still in short supply; Kit A and Kit B drugs are not fully available with the sub centers.

Infection control, sterilization of equipments and bio-medical waste disposal guidelines and practices are not being followed in the State as none of the districts visited was following the guidelines of the same. System for waste segregation and disposal requires urgent attention. Awareness and knowledge building is required at all levels (low even at the district hospital level). Placenta and blood-stained/soaked waste handed over to family. Should this tradition be promoted? Placenta should be handed over to family only after disinfection.

There is no Grievance Redressal System at the facility level however a SMS based grievance Redressal system has been constituted by the State in one district on pilot basis.

4. Outreach Services

The sub centre provides outreach services. Generally, however the records on activities conducted at the farther villages from the centre are less compared to proximal ones. VHNDs are planned in coordination with ICDS. But the coordination is limited to holding the event and not yet gelled into a system that takes care of the needy mother and children. Attendance of mothers and children was poor. VHNDs are largely immunization days and other services such as counseling, identification and treatment and follow-up (including referral) of children with growth faltering, ANCs etc are weak. Thus, its impact on the community at large (men, adolescents, mothers not covered by the Aanganwadi) is limited, if any. Bi-annual (every six months) nutrition and health months are conducted during which vitamin A distribution, bednet impregnation, immunization mop-up, etc. are done Referrals still a major bottleneck in under-served pockets, as observed in both the districts. Vehicles were observed in most facilities. As observed at the Aanganwadi centre in district

Kanker, children who were sliding from Gr II to Gr III malnutrition were not getting attended to as to reverse the trend. Referrals are almost nil as in Nutritional Rehabilitation Centre of District Hospital Kanker, team did not find any referred case from peripheral facility. Same was true of Mothers having low Hemoglobin. The intervention is limited to supplying Iron Tablets. The MPW (M) are generally less available than ANM, wherever they are. Mahatari Express (exclusive ambulance services for transporting mothers for delivery) has been operational but service utilization is very limited. In District Kanker out of 245 Sub-centres 2nd ANMs are present in 11 Sub- centres. There is no distribution of work between them which needs to be taken care of.

Referral Transport Services – Referral transport facilities were available at all most of the centres visited however utilization was very low. No EMRI-108 services “Sanjeevani Express” in Kanker, but started in Kawardha since 3rd Nov 2011. Till 10th Nov, 16 cases transported by EMRI vehicle attached with DH. It is reported by EMRI staff that 2 delivery cases and 14 accident cases were transferred by them (at DH). It is averaging around 2 cases per day and around 35 km per day covering around 15km per trip. However mother drop back to home facilities were not found operational.

During interview with inpatient in DH it was revealed that awareness about this facility is limited and family members transport women in private vehicles. During FGD, people requested that women in Labour and sick children needs to and fro transportation services using local vehicles.

Total number of 412 ambulance available at DH, and CHCs across the State and 146 Mahtari Express (exclusive ambulance services for transporting mothers for delivery) has been given to all blocks Emergency Transport Services – 108 Sanjivani Express has been started in the State in 7 districts.

2010-11 2011-12 S.No. Particulars Jan-Mar 2011 April-Current 1 Total Emergencies Handled 6404 47787 2 Average Trips Per Day 2 4.5 3 Average Response Time (Base to Scene) 20 mins 25 mins 4 No. of Ambulances (all BLS) 36 92 5 No. of Districts 2 7

Mobile Medical units are not present in the State procurement of 30 MMUs is Under process by the State.

5. ASHA Programme

ASHA (Mitanin) programme was started in Chhattisgarh way back since 2002 and has contributed significantly towards rural healthcare services. The Programme has very positive effect in promoting good practices and Mitanins are contributing significantly towards the utilization of public health services in Chhattisgarh.

60,000(approx) Mitanins are working in Chhattisgarh currently with a very well established support structure with Mitanin trainers, block coordinator, block nodal officer, district coordinator, district nodal officer. However it is not known how many of the registered Mitanins are functional at any given point of time. Mitanins report to their supervisors and districts coordinator but rarely to the RCH nodal officer or the BMOs. This non communication has been pointed out by district nodal person and the BMOs contacted on this issue.

In district Kanker, 2776 Mitanins are working currently out of which 2606 have completed trainings of 14th & 15th rounds.

Interaction with Mitanins: Vill Mitanins identifying drugs Baar Deori, supplied in drug kit

Skills and knowledge of Mitanins is very good. The knowledge levels of Mitanins on critical aspects like care during pregnancy, post-natal care, immunization, complementary feeding, diarrhea and malaria management etc. were found to be adequate for a large proportion of Mitanins. The team found that Mitanins were able to correctly identify the drugs supplied in the dawa peti. Mitanins have helped increase institutional deliveries, immunization, mother and child attendance in the VHNDs, utilization of public health services and better hygiene in the community. They have a good sense of empowerment.

The average take home amount per Mitanin is very less ~Rs 200 per month only due to very small sizes of hamlets (10-20 families in some hamlets). The current system of paying incentives to Mitanins is from the concerned facility. Incentives for JSY, Family planning and Cataract are paid by facility where the patients are taken to and Immunization incentive is being paid through the ANM which gets delayed, some of the Mitanins have not got their immunization incentive for almost a year. Payments made to Mitanins are very irregular and needs to be regularized by the State.

The average attrition is within acceptable levels. According to external evaluation, there is no single predominant cause for attrition. The reasons include death, migration, finding a regular job etc.

State has devised a Grievance Redressal mechanism for Mitanin grievances through a Toll- free Mitanin helpline 18002337575. Orders have been issued to form Grievance Redressal Committees at Block, District and State level.

Bank accounts are being opened for Mitanins and accounts of 55% Mitanins have been opened till date.

Drug kits have been distributed in Mitanins but timely replenishment needs to be taken care of. Previous 3 replenishments were done in Apil-011, December-2010 and July 2010 in district Kanker.

6. RCH-II (Maternal Health, Child Health and Family Planning Activities)

At the outset, it needs to be mentioned that there is considerable improvement in the field of Maternal and Child Health and in the field of Family Planning. Though the progress made is slow, yet, it may be said to be in the right direction.

ANC Registrations in District Kanker: Year Achievement % Target 2005-06 18327 18199 99.3 2006-07 18350 18258 99.5 2007-08 17589 17202 97.8 2008-09 16637 16870 101.4 2009-10 16075 77.34 20785 2010-11 16085 16762 104.21

2011-12 (Till Sep) 17787 8083 45.44

ANC Registration Achievement %

150 99.5 101.4 100 104.21 99.3 97.8 50 77.34 % Achievement 45.44 0 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 (Till Aug)

% of Inst. Delivery out of total deliveries 70.00 64.72 60.00 52.35 61.80 50.00 40.00 34.91 % of 30.00 Inst. 18.06 33.64 20.00 Delivery 21.33 10.00 0.00 2005-06 2006-07 2007-08 2008-09 2009-10 20010-11 20011-12

There is improved antenatal registration, check-ups, and referrals; fixed day strategy to fill HR gaps was appreciated by communities. There is increase in institutional deliveries, stay for 48

23 hrs, and diet provisions were available at CHC level (Kanker).

In Kawardha around 60% of reported deliveries are home deliveries. Over last 5-6 years institutional deliveries increased from around 20-25% to 40-45% (of reported deliveries). ). All deliveries in the CHC and PHC records were normal deliveries and the complicated cases are referred to Raipur.

RMAs are filling critical gaps of MOs in PHCs and CHCs.

Quality of ANC needs to be improved as Hb estimations are not being done on regular basis. Quality of institutional deliveries also needs improvement. Partographs are not being used in all facilities. However are being used at Sub Health Centres where ANM is SBA trained. Only one size of Ambu bag and mask was available in most facilities. Follow-up of anemia, especially severe anemia, sickle cell anemia is not being done – only referred but not tracked.

Newborn care corners are being established at every facility. Radiant warmers are present but in most of the facilities are not functional and 200 watt bulbs are being used in new born care corners. Post natal follow up of mother and child is not being done. Care of low birth weight babies, Recorded newborn weight is almost rounded off at most places. Immunization at birth had varied practices- some being immunized at the facility where as some being immunized at the Sub- centre concerned. Even immunization during ANC had the same issue – a pregnant women coming to the PHC for ANC was sent to sub-center for TT. Although system of tracking in place but needs strengthening (No tracking of full immunization in Kawardha)

Payments of JSY are being made through cheques at the facilities although with a time lag of 15-20 days between delivery and receipt of cash incentive in some facilities. Support document of JSY payment in CHC Pandariya and PHC Kukdur was found to be not matching.

Citizen charter and Janani Shishu Suraksha Karyakram (JSSK) guidelines were displayed only in District Hospital Kawardha but nowhere else.

JSY Payment being made through New born care corner: PHC Korer, cheque: CHC Antagarh, Kanker Kanker

Interaction with JSY beneficiary: Vill Baar Deori, Kanker

Interaction with JSY beneficiary- Para- Bazarpara, Village Baar Deori, Block Dhaneli kalan Beneficiary‟s name: Smt. Sharda On interaction team found out that 3 ANC were done, immunization was done both for mother and child but breast feeding was delayed by half an hour and no post natal check up was done. Child was normal and weighed 3 Kg at the time of birth. Delivery took place at CHC Dhanli kalan.

MCH centres in the State: S.N Level Proposed Functioning o 1 L3 75 26 2 L2 332 119 PHC, 84 CHC * 3 L1 1468 715 SHC, *

State has proposed 1875 facilities into L1, L2 and L3. Only 944 are currently functional due to the scarcity of human resource and limited training capacity of the State.

Systems for review of Maternal and Infant deaths have been brought into action and State and district MDR committees have been constituted. – First information through pre printed inland letter. – Online death reporting.

Janani Shishu Suraksha Karyakram (JSSK) is being implemented in the State. Health care providers are well aware of this programme but community needs more awareness about the entitlements. Referral transport mechanism is weak so demand is less.

No. of private providers facilities accredited for JSY 171 Maternal Health 0 Family Planning Services 108

171 private facilities for JSY and 108 private facilities for Family planning services have been

25 accredited in the State. Quality of services being provided in these facilities needs to be ensured.

In Family planning practices, the trend is increasing, but while interacting with the PWs during VH&NDs, the followings were highlighted by the pregnant women: 1. The onus of family planning practices is on the women 2. Male participation in Family Planning practices is negligible 3. Women are less aware of IUCD Cu T 380 with 10 years life 4. Majority of the women are on OCPs

There is Poor documentation/ records on family planning services across the facilities. Records on Post operative complication of FP are not maintained.

Maternal Death Review (MDR) Though MDR has been initiated there is underreporting of deaths. While most reported deaths had been investigated, no detailed review is taking place. There is a lack of understanding of the concept of MDR and casual approach of the officials was observed.

Though Kawardha had a District MDR Committee, meetings were not happening regularly hence none of the reported maternal deaths had been reviewed by the committee so far.

School Health programme School health programme is in partnership with the education department in the state and districts. Partnership with ICDS is however remained weak even when MDM is in place in all government schools.

A set of four booklets to sensitize teachers and to facilitate health communication is in place. School visit and cross reference to these materials however reveled that these materials were not available at the school.

Along with this a health card for twice a year heath screening for consecutive three years has been positioned in partnership with the education department. Though the education department logo and ownership is not visible on either of the health card or the communication booklet. Date of observation is not available in the two scheduled screening thus growth monitoring and follow-up is not possible as recorded in the school records. The health card is not complemented with a list of identified children and hence follow-up is not possible. Only aggregate data is used for reporting. Follow-up of identified deficient, disabled children is thus not reported.

At Kawardha in July-Sept 2011 out of 1142 primary schools 910 schools; 283 Madhyamik schools out of 545 schools, 67 of the 87 high schools and 38 of the 49 higher secondary schools has been covered under the programme. The student beneficiaries were 58486, 23224, 7213 and 3507 respectively.

Interdepartmental and programme linkages is weak. A state level initiative to identify schemes and programme and policy review would help to identify the spectrum of linkages available and utilized at state district and block level.

7. Preventive and Promotive health Services including Nutrition and Inter-Sectoral Convergence

Anaemia is a major problem in Chhattisgarh. However even the district hospital has not focused on the detection and treatment of anaemia. District hospital has cell counter, colorimeter and auto analyzer but still persist in trying to Hb estimation by sahli's method .PHC and sub-centres have sahli's Hemoglobinometer but it does not appear to have been correctly and consistently used. As screening for anaemia is not being done there has not been any programme for parental iron therapy in anaemic pregnant women.

There is good promotion of „early initiation‟ of breastfeeding and exclusive breast feeding for six months at facility and outreach levels however Counseling and support for exclusive breast feeding for 6 months and adequate complementary feeding needs more promotion. There is Improved coverage of Vitamin-A supplementation, regular periodic de-worming. Selected indicators have been integrated into MCTS. There is good availability of ORS and Zinc at village level

Assessment of nutritional status of children coming to OPD/IPD, e.g. weight, screen for anemia, Growth Monitoring and promotion including identification and management of undernourished children, referral of severely underweight is not being done. IFA supplementation for children remains neglected. Skills enhancement of workers, RMAs/doctors for effective counseling; and Hb testing for ANMs, laboratory technicians needs to be done. MCTS should consider tracking a full set of core nutrition indicators up to 2 years.

For treatment of severe acute malnutrition, State has taken steps towards setting up more NRCs; In facility-based management: – Referral network to be strengthened; Closer coordination with ICDS at all levels – track at monthly meetings; Mitanin and AWW role – Motivation to stay full course; incentives to mothers is already being provided in the State. – Follow-up protocols to be established and followed

Screening and appropriate management needs to be emphasized– all underweight children do not need admission to NRC; RMAs may be trained in this regard.

Convergence: Positives: Mechanisms for convergence with ICDS institutionalized at the village level are being developed – Monthly VHNDs at AWCs happening regularly – Six-monthly Health and Nutrition months are also being organized Joint home visits (mostly AWW&ANM) to households with pregnant/nursing mothers. Disease control program interventions at VHNDs

Areas for improvement: Quality and scope of VHND – Child Growth Monitoring and Promotion to be priority focus area – Identification and appropriate management, follow-up of growth faltering/

under-nutrition, including referral of severely undernourished children Strengthening of VHSNCs – clarity of role and capacity building Coordination with Total Sanitation Campaign with involvement of VHSNCs and PRIs

8. Gender Issues and PCPNDT

At State level, Director of Health Services, Dist. Level – Collector, Block Level – Block Medical Officer are responsible for the implementation of PCPNDT.

Currently, 462 facilities are providing USG facilities in the State.33 facilities are registered in public sector (State Govt. – 32 and Central Govt. – 01). PCPNDT act has been implemented in all of these facilities.

There is no expenditure of PCPNDT IEC budget. IEC on gender, valuing the girl child, PCPNDT, display sex-disaggregated data – community interactions did show some son preference, as also use of Ultrasonography.

PCPNDT Advisory committee meetings to be held regularly. Regular inspections of USG clinics to be undertaken. No cases have been detected, complaints received, or filed – State may publicize, involve NGOs. Preserving the good sex ratio needs effort; very little effort seen in the State.

Attention to separate toilet facilities for women in OPD facilities needs to be provided.

9. National Disease Control Programmes (NDCP)

1. NVBDCP:

Month 2009 2010 2011 TPC Pf Death TPC Pf Death TPC Pf Death Jan 1073 664 0 4974 4072 1 29047 7169 2 Feb 4127 3293 0 5450 4219 0 7476 6165 1 March 4299 3399 0 6198 4782 0 9071 7024 2 April 2670 2107 0 4740 4080 0 5618 4391 0 May 3443 2662 0 5746 3637 1 5092 3955 2 June 4595 3376 0 5489 3899 0 6807 5300 1 July 29811 22936 3 10133 8222 8 13170 10644 4 August 15273 12378 3 16549 12620 5 15362 11943 1 Sept 18430 14370 1 18310 13822 0 Oct 10613 9071 2 15802 12442 2 Nov 12507 1070 2 25885 20706 25 Dec 15748 13011 0 27665 23995 5 Total 122589 97977 11 146941 116496 47 91643 56591 13

Human resource: State: Currently only- out of 6 state consultants 2 are in place. At the state level, 10 out of 11 VBD Consultants are in place. Although majority of MTS positions are filled by the state (39 out of 66 MTS).10 Laboratory technicians are lying vacant across microscopic centre. District: There is a shortage of manpower at different levels .5 MTS vacant out of 6, 2 Lab technicians out of 3, MPHWs 24/60, health supervisors). AMO post is vacant at district. District malaria officer holding another programme charges of IDSP, DTO and Mitanins Nodal. Programme Finance: The salary DEO is not received in the district at the time of visit. The spray wages were also realized in time. A fund for the capacity building is received by the district. RD kits were utilized at mainly at Block microscopic centres. All indoor emergency and fever complicated cases were diagnosed with Kits. IRS: Two round of IRS (DDT) are practiced in selected high endemic areas of blocks of district. There is shortage of the insecticide during year 2011-12 due to the delay in the procurement.

LOGESTICS TO MITAININ: Mitanin are supposed to collect Blood smear, performed RDT and treat malaria cases with ACT, and referred complicated severe cases to nearest health facilities. But presently, they having only limited chloroquine tablets .The RD Kits and ACT not available in the drug kits .Generally they have the necessary knowledge but lack skills, for example, in preparing slides and RD Kits. Programme Logistics: ACT available at Block and selected Primary health centres. There is disparity in the demand and supply .The ACT at village level is not still streamline in the high risk endemic blocks

INCENTIVES DISTRIBUTION: Mitanins have not started receiving incentives for malaria activities. Presently the presumptive treatment and Radical treatment by giving chloroquine and Primaquine to patient practiced in the some field area of world bank districts.

IEC: The IEC activities are well managed in the district. The wall painting, posters and banners are well displayed at health facilities. The PRI members and villagers are well aware of the malaria as public health problem in the area and demanded bed nets for protection. World bank vehicle from NVBDCP to earmarked to DMOs for field movement is utilized by upper inter and intradepartmental officials.

Morality reporting: After going through the malaria mortality statistics among the district malaria office (0), sentinel site (6), District Hospital (6), HMIS (3) and IDSP etc. there is variation in the mortality figures. The coordination is lacking among the different reporting system in relation to malaria deaths.

VHSNC: Committee has been formed at village level. The funds are effectively used by committee as per guideline to IRS activities. They are least aware about vector breeding places and how to reduce.

LLIN intervention success story Malaria is major public health problem Antagarh block of Kankar district. The API of the block in 2006 was 47.98 with Pf 97.6% .The superimposed transmission in the block is maintained by the vary effect vector Anopheles fluviatilis and Anopheles culicifacies. Over the years the ABER ranges from 27.8 to 47.98 .Area are under the regular two rounds of IRS*(SP) after 2004 with good coverage. The LLIN micro plan prepared at block level and nets were distributed with strong PDS network by involving of local community panchyat leaders in the block during 2009. During the net distribution, the BCC carried out before and after distribution at villages and hamlets. Outcome of LLIN and regular intervention reduce the API and malaria incidence to 17.28(1242)2010 from 70.65(4942)2006”.

Bednet Tribal women using bed-net for protection against Malaria

RNTCP: Sl. No. Details 2011-12 1 Suspected Case detected 82275

2 Sputum positive (10 to 15%) 10013 (12%)

3 Treatment started in 7 days 20679

Annual Case detection Rate 4 116 (53%) (>151/lakh/year) New sputum positive treated 5 8146 (52%) (70%) Sputum Conversion rate after 3 88% 6 month(90%) Registered cases. 7700 No. of Patient cured 6686 7 Cure rate (85%) 80 Success rate (90%) 87

NLEP:

Sl. Indicators No. 06-07 07-08 08-09 09-10 1 New Cases Detected 9040 6056 6215 7646 2 ANCDR per 1,00,000 40.00 26.30 34.00 32.20 population 3 Cases on record 4515 3322 5465 5304 4 PR per 10,000 population 1.99 1.45 2.38 2.24 5 Gr-II disability (%) 169 252 339 412 (2.80) (3.51) (4.33) (5.39) 9 TCR - 92.23 92.66 95.13 10 RCS - 128 153 113

For entire year Apr’10- 2011-12 Apr- Sl.No Indicator Mar’11 Sept’11 1 New Cases detected 7383 3743 2 Nos of RFT cases 7733 3852 3 Nos of Under treatment cases 4952 5168 4 Prevalence rate 2.08 2.13 5 ANCDR 30.95 16.67 6 Re constructive Surgery. 273 73 7 Grade II disability 376 181 Target or 2011-12: Indicators target Achievement i) RCS 250 73 ii) ANCDR 31.7 16.67

ANCDR is relatively constant over past 5 years with slight increase during 2007-08 and 2008- 09. In Kawardha NCDR of 23.64 but PR of 1.72 (against a target of 1.0) MCR footwear and self care kit is being distributed in Kanker. No relapses have been confirmed at district level. 2 Re constructive surgeries done during 2010-11. Nil during this financial Year. Treatment completion rate is reported to be over 90%.

NPCB: Target achievement is increasing over past few years. For Kanker, 1206 cataract operations have been done during FY 2011-12 from target of 3500. In Kawardha there is no operational Eye OT in the district. 2 Eye Surgeons (at DH) and 3 Ophthalmic Asst. (at PHCs) available in the district. There is 37% achievement of cataract

operation target.

NIDDCP: NIDDCP cell found non functional in both the districts.

IDSP: S.N DISTRICTS NO. OF RUs Average up to 34 weeks (%) O Timeliness Completeness Not Available

1 Baster 374 23% 30% 70% 2 Bijapur 74 9% 32% 68% 3 Bilaspur 387 65% 71% 29% 4 Dantewada 286 14% 21% 79% 5 Dhamtari 167 89% 94% 6% 6 Durg 437 38% 61% 39% 7 Janjgir 246 95% 96% 4% 8 Jashpur 300 35% 51% 49% 9 Kanker 212 92% 93% 7% 10 Kawardha 144 68% 78% 16% 11 Korba 214 35% 61% 28% 12 Koriya 157 39% 72% 28% 13 Mahasamund 219 83% 98% 2% 14 Narayanpur 56 8% 22% 78% 15 Raigarh 322 72% 83% 17% 16 Raipur 562 61% 77% 23% 17 Rajnandgaon 306 61% 76% 24% 18 Surguja 587 32% 33% 20% TOTAL 5050 56% 82% 51%

10. Programme Management

Level No. of No. of contractual No. of contractual Total Regular Staff in important support staff such as Number of Staff positions like programme assistants/ Staff in Programme DEOs/ typists/ peons SPMU managers and Consultants who have been employed for their technical expertise SPMU 3 10 25 35 DPMU 0 57 60 117 BPMU 0 161 690 851 Total 3 228 775 1003

Programme management is being done at three levels: State Level- State Health Society, District Level- District Health Society, Block Level- Block Medical Officer, BPMU and his

team.

Functioning DPMUs is present in the districts however Posts of Block Programme Managers, BADA are vacant in the districts. JDS meetings are irregular and are mostly influenced by block/ district level needs. Utilization funds by the JDS is not in accordance with the guidelines and JDS is being used for recurring expenditures like salary, Paying electricity bills at SHCs. DPMUs not conducting mandated monitoring visit. Recording system in both the districts found to be poor; especially financial / accounting record keeping

The PMUs both at the State and at district level are a dynamic team of workers with high potential. The managers are good, dedicated, but lack of supervisory skills, which required to be supported by regular health services managers, both at the State level and at the district level. BPMUs are also active although functional only at some places and found to be accountable.

The lack of regular appointees for programme management is a gap in implementing NRHM in general and the vertical national health programmes in particular. The block PMSUs were either absent or has not taken roots yet.

11. Procurement System

State is in procedure of constitution of Chhattisgarh Medical Service Corporation (CGMSC). All Procurement and Logistic support will be maintained by CGMSC

– CGMSC has been registered. Recruitment for CGMSC is under process and it will be operationalized by Feb 2012. – Procurement and logistic system for drugs and supplies is on demand basis – System of procurement of drugs at state and supply to the district level is established in the state – State and district procurement cells are in place. District procurement cells have been established in each district. – To maintain the transparency and efficacy of procurement, online global open tendering procedure is being used in the State. – Procurement manual (CGBKN) is being followed in the State – ProMIS is not operational at state or district level warehouses

12. Effective use of Information Technology

Mother and Child tracking System: CHCs & DHs PHCs and Other Other than CHC Sub- Area / Health facilities at or above block centr Hospitals CM above SC but level but below es / General O below block level District Level Hospitals office No of data 148 entry points

No. of facilities Village wise area base reporting which cover beneficiaries of all reporting on facilities MCTS portal

No. of ANMs/ 0 560 0 125 42 DEOs trained No. of facilities using CSC (Common 0 0 0 0 0 Service Centre) SWAN centes for data entry No. of facilities generating Work plan generating for all villages work-plan using MCTS No. of facilities 741 148 18 by doing (By verification of (By supervisors) BADA/B DDO data PM) s

HMIS (April- Sept.)

Month SC PHC CHC Month Fille Tot Total % Filled % Total Filled % Name d al

April 4872 4739 97.27 727 688 94.64 172 143 83.14

May 4872 4717 96.82 727 695 95.60 172 144 83.72

June 4872 4741 97.31 727 689 94.77 172 145 84.30

July 4872 4758 97.66 727 689 94.77 172 142 82.56

August 4872 4730 97.09 727 684 94.09 172 146 84.88 Septembe

r 4872 4734 97.17 727 688 94.64 172 141 81.98

Month SDH DH Month Name Total Filled % Total Filled %

April 19 11 57.90 17 17 100

May 19 10 52.63 17 16 94

June 19 10 52.63 17 17 100

July 19 10 52.63 17 17 100

August 19 12 63.16 17 17 100

September 19 10 52.63 17 17 100

State has modified EMCTS Software and objectives and tracking system for Mother and child as per National guidelines. Nodal officer for MCTS has been appointed for block and District level. The quality of data filled in MCTS registers needs authentication in both the districts visited.(Kawardha: as per the registers seen, 80% women were not anemic, majority had body

34 weight between 40-50kgs, and everyone had normal BP, and all babies weighted between 2.5- 3.5kgs. Still around 50% backlog in computerizing the registered women. No plan/strategy for covering the missed out women and children). Feedback is not being provided by district and block levels to ANMs/HV‟s

A parallel manual compilation of report is in place for the programme management portal at www.cghealth.nic.in/health.

State has started E-Mahatari (SMS based maternal child tracking system) pilot project has been started in 1 district of the State (Dhamtari) and will be implemented throughout the State upon successful completion of pilot project. Mobiles have been distributed to ANMs in the district and data is being entered through SMS based system. The team found out that data entry procedure is simplified and ANMs are also comfortable to use this system.

District Kanker- 204 SC/28 PHC/08 CHC/01 CH /01 DH are reporting in HMIS portal and forward monthly reports to District. District Hospitals and Sub- centres are reporting timely, middle facilities have some gaps with only 50% Civil hospitals reporting timely. Districts needs to check monthly consolidate data and send feed back to nodal officer and Block level officers. Data Entry is done at 7th of the month from Data center.

HMIS data is not being used in District/Block level planning. Regular feedback is not being given to block level officials and supervisors for betterment of HMIS. It was observed in Kawardha that ANMs did not have a duplicate copy of HMIS forms with them and they complained of lack of feedback from supervisors on the data reported (especially regarding data validity and program implications). Training is given to BADA/PADA but refresher training required to improve the data quality. Data center has been established in all Block levels and computers are connected via LAN . However Internet connectivity is an identified problem in Kawardha.

MIS data as found at CHC Pandariya, Kawardha for the block was not matching with MCTS data. Internal check of the HMIS data is not done. The monthly meeting agenda of ANM supportive supervision does not include any discussion of MIS data problems as the identified problem of the MIS is not updation of the MCTS booklets by the ANMs. Observations in the monthly data feeding and quality are not being followed up in the next month meetings. The data gets rectified without an expected feedback to the front line workers who are collecting the data. Committed data levels were not reported at the block and district levels. CMHOs do not validate the district reports. The utilization of available data for monitoring and planning was not very evident and needs more orientation of Block and District officers in this area.

13. Financial Management

The state of Chhattisgarh has been showing a very erratic trend since the beginning of NRHM, as far as funds utilisation under NRHM is concerned. The total NRHM funds utilisation (including the flexipools and disease control programs) were consistently more than 100% of the releases in the initial three years, which fell to 65% in 2008-09, increased to 91% in 2009-10 and again fell marginally to 87% in 2010-11. The total NRHM funds released and expenditure reported by the state is shown in the figure below.

Figure 1: NRHM Funds released and expenditure in Chhattisgarh state Chhattisgarh: NRHM Funds

350 300 250 200 150 100 50 0

Rupees in crores in Rupees 2005- 2006- 2007- 2008- 2009- 2010- 06 07 08 09 10 11 Releases 94.13 149.11 190.85 249.72 261.64 327.23 Expenditure 107.37 187.69 197.77 162.12 239.06 285.56

Source: NRHM MIS as on 31st March 2011

We can postulate that the additional funds spent under NRHM in the first three years came from the state‟s own contribution to NRHM. But, looking at the state contribution, there were no state contributions mandated under NRHM in the first two years (the 10th plan period) and in the third year, the state contributed only 42% of what it was supposed to contribute (as per the 85-15 ratio of centre-state share in the 11th plan period). The contribution of the state towards NRHM as a percentage of what it was required to contribute, increased 2008-09 onwards, but that period also coincides with NRHM expenditure falling below central releases.

This does raise the question about the source of additional funds spent under NRHM in the first three years by the state of Chhattisgarh. Also, the decline in 2008-09 and the subsequent

36 less than 100% spending was explained by the state as a result of the governance issues faced by the state (with senior officials facing corruption charges) and subsequent rationalisation brought in the governance and financing.

Chhattisgarh‟s state contribution to NRHM is shown in the figure below.

Figure 2: Chhattisgarh State’s contribution to NRHM

Chhattisgarh: State contribution to NRHM 60.00

50.00 40.00 30.00 20.00 Rs. in crores in Rs. 10.00 0.00 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 Required contr. 0.00 0.00 28.52 41.85 43.67 55.01 Actual contr. 0.00 0.00 12.00 35.00 31.13 47.00

Source: Chhattisgarh states presentation to 5th CRM team on 9th November 2011 at Raipur

The erratic trend of expenditure under NRHM in Chhattisgarh becomes more pronounced when we look at the RCH and Mission flexi-pools separately. Under RCH flexi-pool, Chhattisgarh started with 93% expenditure (of releases) in the very first year, which fell marginally to around 80% in 2006-07, then suddenly increased to almost double the release in 2007-08, then stabilising around 80% in the two subsequent years and climbing to almost 90% in 2010-11. In contrast, under the Mission flexi-pool, the state started with a low rate of expenditure (of the releases) of less than 20% in the first, which suddenly shot up to 66% in 2006-07, then kept falling to 20% and less in the two subsequent years, followed by a spurt of around 60% in 2009-10 and almost 100% of releases spent in 2010-11. The funds released and spent by the state under these two flexi-pools are shown in the figures below.

Figure 3: Releases and Expenditure under RCH flexi-pool in Chhattisgarh

Chhattisgarh: RCH Flexipool funds 120.00 100.00

80.00 60.00 40.00 20.00

Rs. in crores in Rs. 0.00 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 Releases 31.70 48.17 36.02 63.01 81.52 102.46 Expenditure 29.44 38.05 66.05 47.60 61.79 89.94

Source: NRHM MIS as on 31st March 2011

Figure 4: Releases and Expenditure under Mission flexi-pool in Chhattisgarh

Chhattisgarh: Mission Flexipool funds 100.00

80.00 60.00 40.00

Rs. in crores in Rs. 20.00 0.00 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 Releases 29.10 61.75 64.13 54.18 82.42 80.00 Expenditure 4.89 41.00 13.06 8.92 47.49 79.86

Source: NRHM MIS as on 31st March 2011

The big fluctuations in expenditure under NRHM in Chhattisgarh indicate inconsistencies in resource allocation and booking of expenditure in the initial years. But, as reported by the state, Chhattisgarh has taken conscious steps in putting the systems in order and have begun rationalising the financing and governance since 2010-11.

Presently the Financial Management is being managed under the close supervision of the Mission Director with the support of State Finance Manage and other support staffs at State and District level. The whole financial management system was analyzed and activity wise report is as under:

1. Electronic funds transfer system: The SHS and DHS are transferring the funds through E-transfer to the receiving institutions. Although it is not 100% but all the major institutions (viz. from SHS to DHS, Directorate, SHRC, EMRI etc and from DHS to Blocks etc) are covered under E-transfer. The DHS are transferring the funds through E- transfer to the CHC and PHC Level. 2. Tally ERP 9 software: The ERP 9 is used only by four districts (Janjgir, Durg, Dantewada, Raipur). It is planned to cover all 18 districts by end of Dec 2011. The state is not working towards any other software for Accounting. In Kanker District it was observed that the Tally ERP-9 software had expired on last year at district and block levels. In Kawardha, Tally was installed only at the DHS level. 3. Release of Funds & Utlisation : All the funds are utilized for the approved activities of PIP with reference to key activities and monitorable targets. 4. Auditing procedures: The Statutory Auditors appointed as per GOI norms. The Statutory Auditors observations are being regularly followed by the State & Districts. The Concurrent Auditors are also appointed as per norms and the districts are conducting the Audit on a quarterly basis. 5. Delegation of Financial & Administrative Powers: Financial & Administrative powers have been delegated down the state, district and block levels as per GoI guidelines. 6. Training measures: Previously Training had been organized for State, Districts and Block personnel on accounting and usage of Tally software. In the current FY (by end of Dec 2011) a comprehensive training on Tally accounting is planned.

7. HMIS: Regular updating is done by the districts on web portal (seen up to September 2011).There is no window on the portal for uploading the State level data on GOI HMIS web portal. 8. Maintenance of Records & MIS : The FMR is being submitted by the districts mostly on time. The blocks are now submitting the FMR to districts, but are hampered by lack of accounting staff at block level (as observed in Kwardha district). 9. Integration of financial management processes with NDCPs:  The Integration is yet to fully completed, but the process had begun. In Kawardha district, the CRM team observe that it was integrated and the various programme officers are now getting funds through the DHS.  All the finance and accounts personnel are not a part of state level FMG. 10. Model Accounting Handbooks: Sent to all Districts for Implementation by the Finance Staff of the sub-Districts level Institutions, but these being inEnglish need translation in Hindi for better understanding at the block level and below. Training is planned by the state on these guidelines in the current FY (2011-12). 11. Procurement: The SHS has adopted the “State Bhandar Kraya Niyam” guidelines for procurements of Medicines & Equipments. 12. State contribution under NRHM: SHS is getting the State Contributions regularly form the State Government. A total sum of Rs 169.06 crores have been received so far. The details are as under:

Year To Receive Actual Received Shortfall 2007-08 28.52 12 16.52 2008-09 41.85 35 6.85 2009-10 43.67 31.13 12.54 2010-11 55.01 47 8.01 2011-12 30.03 43.93 -13.9 TOTAL 199.08 169.06 30.02

13. Pendency of UCs from 2005-06 to 2010-11: UCs for the year 2009-10 and 2010-11 were amounting Rs. 137.32 crore under RCH and 2007-08 of Rs. 17.95 crores, 2008-09 of Rs. 54.18 crores, 2009-10 of Rs. 82.42 and 2010-11 of Rs. 80.00 crores. Total amount of Rs. 234.55 crores. 14. Advances : Longstanding Advances mainly seen in the JDS/RKS Grants, AMG, Untied funds, VHSCs and Infrastructure (Constructions) activities. The CRM team observed that these are mainly due to the staff at lower level facilities and VHSC being unaware of how to spend the money and book the expenditure. Regarding constructions, it was observed that the funds are given to other agencies (like PWD) and these it becomes difficult to obtain UCs from such agencies. Also, the shortage of accounts personnel in the CHC, PHC causes problems in obtaining UCs from the periphery. 15. Untied funds and AMG to District Hospitals, CHCs, PHCs, SCs, and VHSCs, whether such releases are being treated as expenditure: Tracking of expenditure done from the concerned Institutions and booking is done on the basis of actual expenditure incurred. No expenditure booked on the basis of advance released to the institutions. 16. RKS constitution, fund utilization and the accountability and RKS (Jeevan Deep Samiti) Funds: All JDS Funds are utilised according to JDS Guideline & all financial records maintained accordingly. Frequency of meetings is low (the CRM team observed

only one meeting at each DHS, CHC, PHC level as on till date in this financial year). A gap of one month was observed by the CRM team in making cash withdrawal from bank and booking of expenditure in the cash book. While it was good to see the procurement of drugs, X-ray films etc, from these funds when these were in short supply, however, in some cases the team was not able to see regular indenting for some of these items through the system. It is important to strengthen the regular indent/stock system, so that these funds do not fill gaps casued due to inefficiencies in the logistic/supply system. 17. Monitoring and evaluation methodologies: Monthly meetings of DAMs conducted at SHS to address the financial issues and get the monthly expenditure reports. DPMU also started the monthly meeting of BADAs to get the reports. Regular engagement through telephone and email conducted from SHS to DHS and from DHS to Blocks to resolve the pending issues. 18. Expenditures incurred against interest earned on NRHM Funds: Interest earned were mostly left untouched by the DHS 19. Income Tax issues: TDS is deducted SHS and from all eligible DHS. TDS amount is also deposited mostly on time into the Govt. account. TDS deductions certificates are issued to the concerned Societies. IT Returns also filed regularly by SHS & DHS.

Specific Comments on utilization ( Till 31st Oct,2011)

RCH Flexi-pool: Total approval Rs.172.87 crore out of which for Maternal Health Rs.8.94 crore and reported expenditure is just Rs. 2.40 crore (26 %). For JSY, against approval of Rs.68.84 crore reported expenditure is Rs.28.46 crore (41%). Also, the reported expenditure under Child Health is 16% of approved amount.

Heads under RCH Approved for Expenditure till Flexipool 2011-12 31st October 2011 (Rs. crores) (Rs. cores)

Maternal Health 77.80 30.87

Child Health 6.89 1.09

Family Planning 19.11 5.05

ARSH 0.18 0.03

Infrastructure 28.50 10.19

Training 12.03 0.30

MISSION Flexi-pool: Total approval Rs.237.39 crore for 2011-12. Within this Rs.23.68 crore was approved for 60,000 Mitanin (ASHA) against which the reported expenditure is just Rs. 9.12 crore. For Untied Funds, against approval of Rs.26.44 crore reported expenditure is Rs.19.32 crore.

Activity Heads under Mission Approval for 2011-12 Expenditure (till Flexipool (Rs. crores) 31st October 2011) – Rs. crores

AMG 4.89 1.58

VHSC 19.15 14.15

JDS (RKS) 10.29 5.99

UNTIED FUNDS 7.28 4.33

New Construction / 82.63 9.79 Renovation

IEC/ BCC 7.38 1.05

IMMUNISATION: Total approval Rs.5.50 crore against which the reported expenditure is Rs. 1.19 crore (on Review Meeting, mobility support, outreach services). For Pulse Polio, against an approval of Rs.54 crore, the reported expenditure was Rs.4.63 crore.

IDSP: For surveillance preparedness, Training and Staff Salary budget of Rs.2.67 crore approved, against which expenditure reported was Rs.0.58 crore. Funds released by GOI Rs.0.49 crore.

RNTCP: For various components like Civil Work, Lab. Material, Honorarium and Contractual Staff etc. a budget of Rs.14.54 crore had been approved (released by GOI Rs.8.63 crore), out which total Rs.3.67 crore has been reported as expenditure. Programme Officer should see that a detailed expenditure report is also provided to NRHM – SPMU / DPMU.

NVBDCP: Under this programme towards Salary of Contractual Staff and ASHA incentive a provision of Rs.8.14 crore approved. Other approvals for this year under NVBDCP included Rs.0.90 crore for Filaria, Rs. 1.2 crore for Decentralised Drugs and Rs.27.58 crore for Commodity Support. Total expenditure reported under NVDCP was Rs.5.33 crore (Release by GOI is Rs.7.56 crore).

NLEP: For various components like Contractual Staff, ASHA incentive, capacity Buidling, IEC etc. a budget of Rs.2.03 crore has been approved out which total Rs.89 crore has been reported as expenditure.

NPCB: Under this programme towards Salary of Contractual Staff, cataract operation , POL and others operation cost etc. a sum of Rs.4.68 crore was approved and the reported expense is Rs.3.39 crore (releases under this head by GOI is none).

14. Decentralized Local Health Action

State has plans for reaching the unreached and back ward, difficult to reach areas through a decentralized service provision package initiated by Field NGOs active in the RCH sector in the district. 14 PHCs are planned to be contracted to an NGO for running in difficult areas.

15. Overall Outcomes

Institutional Strengthening: Institutions needs to be strengthened to improve service delivery parameters in the next phase. Quality of services delivery needs to be emphasized now.

The state however needs to have a well defined/clear HR policy in terms of the requirement (need), posting, training & deployment of staff particularly specialists and also on the need for multi tasking trainings of MOs and other staff as improvement in Health Human resource support.

On service training and skill up gradations: on service training needs to be regularized for the health staff to enhance their clinical and managerial skills.

District and facility based regular monitoring visits with protocol of visit needs to be put in place at district and state levels. Joint review mission protocol for quality of MCH and RCH service delivery protocols can be used for state/district adaptations. These reports should be followed through action taken report and repeat/ follow-up visit schedules.

16. Mainstreaming Ayush

Chhattisgarh is one of the few herbal states in India. The AYUSH health care set up in Chhattisgarh employs large cadre of AYUSH Physicians. The health services provided by AYUSH network largely focused on primary health care. The sector has a marginal presence in secondary and tertiary health care. In the private and not-for-profit sector, there are many AYUSH clinics, hospitals and nursing homes for in patient care and specialized therapies like Panchkarma.

AYUSH Interventions under NRHM in Chhattisgarh:  Co-location of AYUSH dispensaries in PHCs.  Appointment of AYUSH doctors and paramedics (pharmacists) on contractual basis in the primary health care system.  Inclusion of AYUSH modules in training of ASHA.  Establishment of specialty clinics, specialized therapy centers, and AYUSH wings in district hospitals. List of AYUSH service delivery facilities in Chhattisgarh AYUSH Facilities Numbers Ayurveda college hospitals 1 District Ayurveda Hospitals 6 AYUSH Dispensaries 693 Ayurveda Dispensaries 635 Homeopathy Dispensaries 52 Unani Dispensaries 6 AYUSH Specialty (Panchkarma) Centers 61 AYUSH wings in District Hospitals 15 Specialized therapy centre in CHC 22 AYUSH specialty clinics in CHC/PHC 24 AYUSH Centers 399 AYUSH OPD in CHC 42 AYUSH OPD in PHC 357

Drug Testing Laboratory and Research Centre 1 Ayurvedic pharmacy 1

AYUSH doctors play critical role in the delivery of essential health care services in some of the most difficult tribal areas where allopathic services are unavailable. AYUSH dispensaries are co-located in mainstream health facilities which also provide maternal and child health services. These physicians may be trained on “Essential Maternal Health and Child Survival” for further strengthening their skills on Maternal & Child Health.

146 Ayurved Gram has been formed in the State and they are functioning for promotion of AYUSH based preventive, promotive and curative services in the selected villages by IEC and Health Melas. This has improved the demand side for AYUSH services at village level.

Training of approximately 60,000 Mitanin on AYUSH module “Jadi buti lae kar lae illaj” as a means of propagation and utilization of herbal combinations for common ailments has been completed which helped in widening of AyurvedGram services to the villages.

To better manage the infrastructure, untied funds and patient care services, 17 AYUSH Deep Samiti has been formed based on the guidelines for Rogi Kalyan Samiti under NRHM. 692 up-Samitis are also working under these AYUSH Deep Samiti, albeit without formal registration at dispensary level.

Recommendations:

Facility Operationalization: should be taken in a phase wise manner with the first phase involving fully functional District Hospitals. Facilities with least accessibility to DH should be prioritized for designating FRUs. Infrastructural and staff position should be at the foremost priority at the designated delivery points and levels. Institutional development should focus on operationalising the designated delivery points in terms of infrastructure, manpower and facilities.

In-house civil works unit (with engineers within the health directorate) may be made functional with engineers for every district/group of districts. They may be responsible for tendering and contracts management for civil works and dependence on PWD may be reduced.

Human Resources: State needs rationalize up gradation of health facilities according to notified delivery points (resources, supplies, training, and financial utilisation). A time line and follow up action is required to make a overall strengthening process.

Maternal & Child Health: For accelerating decline in MMR, it is essential that good quality antenatal care is provided and high risk pregnant women are indentified and referred. In addition the gaps in referral mechanism care available for emergency obstetric and newborn cases in FRUs, DH are put in place Across institutions; protocols for management of labour including effective use of Partographs should be operationalized. MDR and IDR should also include social causes of death along with clinical causes. Emergency readiness and designated newborn care corner preparedness in all LR as per the GoI guidelines on Skilled Birth attendance needs to be ensured. For JSSK implementation support system up gradation is of utmost importance for ensuring client stay of 48 hours with in the institution. Referral transport system (other than 108) in facilities needs to be positioned urgently. Standard

43 operating procedures in the accredited private facilities need to be part of the accreditation process and regular review.

Many maternal and infant deaths remain unreported. It is recommended to evolve a system so that all maternal deaths are reported. MDR should be looked as an opportunity to identify gaps in management and to take urgent appropriate steps to avoid similar incidences in future. MDR and IDR should include demographic and case management documentation for and response delay analysis along with cause of death analysis.

Facilities for newborn care including resuscitation and providing warmth are now not available at majority of facilities visited. Skills of the service providers in providing essential care at Birth need improvement. This can prove to be crucial input in accelerating decline of child mortality in the state -with IMR of 53 and NMR of 35 and U5MR at 70 (AHS 10-11),

VHNDs are mainly concentrating on immunization and folifer distribution. The state should take immediate steps to ensure that all essential investigations expected during antenatal period are carried out during VHNDs. For abdominal examination of pregnant women, minimum privacy (examination table, curtains, etc) should be provided. Counseling for family planning, IYCF practices and home based new born care should be done during VHND sessions as both provide a suitable platform for providing counseling services to ANC mothers.

The data collected by ASHAs as in other states needs to be positioned with the Mitanin protocol if not done already to identify newly married couple. This can then be used for increasing the age at first pregnancy and sequenced with post partum counseling would increase the spacing span.

JSY: District/State Administration needs to liaison with the Banks to facilitate availability of chequebooks and priority disbursement of funds.

Child Health: Provision of new born care corners at all L-1 and Stabilisation unit for all L-2 facilities needs to be ensured. Monitoring visits for RI sessions should be recorded and follow up of missed outreach sessions should be done. Indenting process till the village level needs to follow a documentation and reporting protocol which can be used to further strengthening the system.

Nutrition :In many anganwadis balances for weighing pregnant women and under fives are available ; however the coverage and quality of weighing is low. Currently efforts at screening all preschool children for undernutrition at least every three months, using mother & child protection card for growth monitoring for early detection of under nutrition and effective management at community level has not got the attention that it deserves. Even district hospitals do not have the mother child protection cards with growth standards. These cards as well as the growth charts for hospital use need to be provided on priority basis. NRCs need proper linkages with peripheral facilities (AWW and Mitanins) for community outreach and referrals.

Family Planning: Supply of contraceptives needs to be ensured. 48 hours post delivery period can be used for such counselling parents. This system can be also be continued with the

44 mitanin and the ANM at the VHND sessions. Distribution of contraceptives by Mitanins needs to be started on priority as per the GoI guidelines.

The mitanin system (a higher concentration than the ASHA population coverage at 1/400 population) can be used for effective outreach. The mitanin reporting system must have reporting collateral to the BMOs and the District nodal person rather the state level reporting as of now. Identification and strengthening of active Mitanin is required to understand the geographical spread and strengthen availability of the outreach workers.

The state currently has good child sex ratio but this should not lead to complacency. There have been some reports of the increasing access to clandestine sex determination and sex selective abortion. District and sub district advisory committees on PCPNDT need to meet regularly as per guidelines. Sensitization workshops for PRIs, ASHA, Anganwadi Workers, NGOs, Social Workers Lawyers, Media & Medical Personnel etc in districts to be held regularly. The state needs to ensure that regular and surprise inspections of registered ultrasound clinics are strengthened across all the districts and strict checking of form F to be done.

IDSP: The posts of epidemiologist need to be filled up. The data for IDSP should be kept in duplicate at the facility level also. Data from Accredited private facilities can be included in the IDSP monitoring. The ANM based local reporting system needs strengthening.

NVBDCP: 2 rounds of regular spray. RD kits and ACT should be available with Mitanins. The key Post of AMOs, Malaria inspectors, LTs, MTS and MPW (M) needs to be filled.

Training should be undertaken for RTI/STI, IMEP, IMNCI for MOs and nursing staff after building the capacity for training. State Govt. may seek technical support from NIHFW. Follow-up of the trained personnel should be taken through monitoring and evaluation exercises to monitor outcome of the training and if needed reorientation training should be provided.

Orientation of RMAs should be done towards National Programmes Efforts should be made to enhance their clinical skills also as they are bridging gap of MOs in rural areas.

Drug procurement and availability at the peripheral facilities needs to be ensured

The suspected cases of Sickle cell Anaemia found to be positive for solubility test at the sub- district level facilities should be provided linkages with the District Hospital for confirmation of the diagnosis and screening of the rest of the family members for possibility of Sickle Cell Anaemia along with regular follow up and antenatal screening in pregnant women. The resources like the electrophoresis machines at the District Hospitals should be maximally utilized to combat the public health problem of sickle cell Anaemia in the State.

Plan a public health intervention for Sickle cell Anaemia with concerted efforts for care including provision of linkages for higher care.

ICTC counsellors in the State can be used for genetic counselling, nutrition, family planning etc, they may be trained at Raipur Medical College

Regular Monitoring of the facilities for service utilization should be conducted and corrective measures needs to be undertaken

Technical/operational Guidelines: While the district officers along with the Medical Officers in charge of facilities are required to operationalize the facilities – Technical/operational guidelines particularly for IMEP and some other issues are not available in the districts. Infection management protocols need to be strictly followed which is not being followed in most of the facilities in the State.

Bio- medical waste-disposal according to GoI guidelines needs to be initiated in all facilities including Blood Banks and the 108 emergency system and the accredited Private facilities

Many Bio-medical equipments are lying unused due to some minor faults. Appropriate mechanisms for early detection and correction of the problems such as Annual Maintenance Contract or recruitment of biomedical engineers may taken up to ensure functionality of the equipment

State may establish Hospital Management Unit under each district hospital comprising of Bio- medical engineer, Hospital Consultant etc. and supported by accountancy and data entry section.

Incentives to Mitanins (ASHA) need to be regularized in the State.

Considering the lower age at marriage and child bearing the State must use the school health programme and the ARSH to reach to young people effectively for achieving higher dividends of MCH and RCH

Finance:

State has recruited Block Accounts & Data Assistant but these posts have been filled only in 60% blocks, therefore priority be given to fill up these posts so as to get proper accounting. And these assistants need more F&A Training.

It was noticed that physical achievement is higher as compared to the reported financial expenditures from the lower levels. It shows lack of reporting. It is therefore recommended that the system of reporting the expenditures from lower levels needs to be strengthened. For this purpose State should devise a Format of Reporting Expenditure (Monthly) for each level right from the level of VHSC and Sub-Centre, PHC, CHC to DHS containing all the program heads/ Jeevan Deep Samiti (JDS) - (according to the need of the reporting facility) so that proper expenditure is reported and advances gets reduced.

Payment for small/ major procurements were noticed being made through cash by withdrawing money from the bank through bearer cheques which is not justified in comparison to making payment of JSY to a beneficiary residing in a rural area and not having bank account. It is therefore necessary that detailed instructions be issued from the State level for making such payments through account payee cheques/ draft/ on-line transfer only.

The State has implemented the instructions issued by the Ministry for Delegation of Financial

& Administrative Powers at district level but it is seen that files are still being sent to the Dy. Collector for approval for transferring the funds from District to Blocks and for payment of Contractual Staff Salary etc. Since, as per the said guidelines once the District PIP has been duly approved by the Dy. Collector, the District CMO is vested with full powers to spend as per the District PIP. Therefore, the said aspect may be reviewed to save the time and energy for smoother functioning.

Maintenance of timely and proper books of accounts is necessary at each level and is back bone of a good financial management system. In order to get proper reporting and authentication of the same and to sensitize the Finance & Account Staff, State may plan to hold a meeting/ conference at least once in a year either at State level or zone-wise to realize them their responsibility and to clear their various queries etc.

Customized Tally Accounting Software: ensure to use of latest tally version (Tally ERP 9.1) up to Block level.

Utilization of Funds for approved activities – Funds used for approved activity but many activities not undertaken like training, ARSH.

Communization: It was seen during the visit that State has taken good steps for displaying the Contact numbers of all the Officials working for the facility at each level and also providing A Public Charter. A position of funds spent on JSY was also seen. In this regard it is further suggested that a position of funds available and spent during each month under each program activity may also be given.

Some Cherished Moments:

FGD at Village Roll- out of delivery of contraceptives by Mitanins, CHC Antagarh, Kanker

Chapter 4

Note on ASHA (Mitanin)

Background

The Mitanin programme in Chhattisgarh was started before NRHM (around 2002). They were selected as a purely volunteer force of helping the community in accessing appropriate healthcare and were made functional at the para/hamlet level. Hence the average population covered by the Mitanins is less than the national norm of 1000 (a Mitanin, on an average coverage covers around 600-800 population, and sometimes as low as 200- 300 population especially in the tribal areas). Also, the pure voluntary nature seems to be different from the national ASHA model of output based payment (incentive driven). On the other hand, the programme having matured over almost a decade means there is a strong support structure in place and the programme has matured (evident by very low attrition rate of 3-4%).

Mitanin Functionality

There are around 60,000 Mitanins working across the state of Chhattisgarh at the para/hamlet level. The attrition rate of Mitanins, as reported by the state is low – around 3-4% (till 2011). The 5th CRM observed their active involvement in the VHNDs in terms of motivating women and children to attend and get vaccinated along with collective the packed nutrition supplement given by ICDS. In some of the delivery points visited by the CRM team, the Mitanins were found accompanying the women in labour and coordinating with the ANMs. Although no Mitanins were found at the District Hospital, the delivery cases and sick children admitted there talked of the support (in terms of guidance and coordination with health functionaries) provided by the respective Mitanins.

The Mitanins interviewed by the CRM teams at the peripheral health institutions and in the FGDs showed good knowledge of health programmes and referral linkage but complained of inability in assisting the patients/beneficiaries in the absence of specialists at the FRU/DH level (which created “trust deficit” among the community towards the public health system). The Mitanins also complained of irregularity in resupply of Mitanin Drug Kit. Some Mitanins complained that when everyone else (meaning the health functionaries and also the Mitanin supervisors) were getting regular payment on a monthly/daily basis, why should they only be expected to work on a voluntary basis?

Looking at the Mitanin payment registers (maintained by the Mitanin supervisors at the district level), it was observed that there were around 30-40% of them who had not claimed any incentive payment (in Kawardha this was around 40%, whereas in Kanker this was a little less than 30%). This was interpreted as a measure of non-functionality by the district/block health officials. But the Mitanins and their supervisors clarified that they (the Mitanins) undertake various activities (like house visits, meetings, etc.) for which they are not paid incentives and they do it on a voluntary basis; hence non-payment/claim of incentive money should not be interpreted as indication of non-performance.

Training of Mitanins

Training of Mitanins is a little different from the module based pattern for ASHAs adopted nationally, mainly because it started much before the ASHA programme. Hence, in Chhattisgarh, 12-13 stages of Mitanin training had been completed for more than 90% of the Mitanins (roughly corresponding to module-5 of ASHA). Presently, 14th, 15th and 16th stages of Mitanin training is underway covering issues like national disease control programme and RSBY (14th stage), HBNC (15th stage) and a revision of 3rd stage along with legal rights and details regarding Mitanin kits (in the 16th stage). This roughly corresponds to module 6 & 7 of ASHA training. The Mitanin training is imparted through sector and block level trainers, who are in turn supervised and coordinated by district and state level supervisors functioning under the SHSRC.

Mitanin Supervisory Structure

The lowest level of supervision happens at the sector level where the sector supervisor coordinates with 15-20 Mitanins (approximately 2-5 Mitanins per Sub Health Centre). Above the sector is the block supervisor, followed by supervisors at the district and state level up the hierarchy. This support structure functions under SHSRC and is fully financed under NRHM using the Rs.10,000 “package” per ASHA. There is routine reporting structure followed under the supervisory structure, but incentive payments are made mostly at the block level through NRHM funds (especially since the Medical Officers are as a state strategy withdrawn from PHCs to block and PHCs are staffed by RMAs1 who do not have DDO powers).

The district NRHM staff did not have detailed tracking of performance and payments made to the Mitanins, which was available with the Mitanin supervisors. The block and district health officials complained of existence of parallel structure for Mitanins under SHSRC (separate from NRHM and Health administration), which according to them, caused gaps in information sharing (especially regarding MCTS). The health administration desired to have more control over the Mitanins (in reporting and payments). This complained seem more at block and district level, but not at peripheral (Sub Health Centre) nor state level.

1 As a state policy, the Chhattisgarh government has started deploying RMAs (Rural Medical Assistants, completing the 3-year Rural Medical Science course) at the PHCs and some identified SHCs while concentrating the Medical Officers at the block and district level. As observed by the 5th CRM teams, it was no doubt strengthening the CHCs, but causing some administrative and financial problems at the sector (PHC) level as the RMAs do not have DDO powers. Also, the ANMs are more experienced (and “senior”) to the RMAs. As a result the RMAs are almost kept out of the RCH functions (as per practice, not as per design). 49

Villages visited for community interactions, FGDs with ASHAs and AWWs

Kanker- AWC Picchekatta, Village Adar Para- Mullah (Bhanupratappur block) Village Baar Devri, Kapsi, Kodagaon and Amrabhat (Dhanrikanhar block) Village Gotitola, Pipraud (Charama block); Kawardha- Vishehara, Daniyakhurd, Chilfi, Behsin Jhori, Pipartola

Key findings:

 Over the last 5 years communities and workers noted a difference in access to services, the quantity and quality of delivery of services, and expressed overall satisfaction in the services they received, both at facilities and outreach at the village. Specifically, opening up of new sub-centers/PHCs/CHCs, facilitation and provision for institutional deliveries at no cost, regular fixed day services for women at PHCs, availability of common drugs/ORS at the village level with the Mitanin; regular VHNDs and bi-annual nutrition and health months at the village level, facilitation of transportation, etc.

 The JSY payments are received in a timely manner by both the beneficiary and the ASHAs

 Both communities and field level functionaries (ANMs, AWWs and Mitanins) noted a noticeable change in community awareness, attitude and behaviors towards for seeking preventive and curative health services, e.g., immunization, ANCs, consumption of IFA tablets, treatment of common illnesses, testing for malaria, TB, hemoglobin, weighing children.

 A positive change in Infant and Young Child Feeding and caring practices, most significantly, initiation of breast feeding within an hour of birth, not giving any pre-lacteals, exclusive breast feeding for six month (although some women did say that they gave water along with breast milk), initiation of complementary feeding on completion of six months, although quality and quantity of complementary feeding needs further effort.

 While malaria endemic, use of bed-nets was mixed. There was a large unmet demand for impregnated bed-nets and request for distribution.

 Spraying had been undertaken in most villages during the malaria season through the untied funds to the VHSCs.

 Village Health and Sanitation committees were largely not active. Their existence was unknown to the communities and also to many panchayat members. Most were, however, aware of the fund of Rs. 10,000 for the village (drawn by the Mitanina and another person), being used for purposes of spraying, bleaching powder in drains and lanes.

 Some cases of TB patients having received full treatment by the DOTS providers and now free of the disease were seen.

 At the field level, convergence between ICDS and Health appears to have improved. Monthly VHNDs and nutrition and health months every six months are held regularly with the participation of functionaries of both departments.

 The Mitanins feel that the overall money they receive by way of incentive is very small. They consider themselves as payless workers and requested that they receive a regular salary/honorarium. They are yet not receiving any incentive for immunization, very few are preparing blood films/slides and thus their incentives are largely related to JSY. They also would like some career path/promotion avenues.

ANNEXURE-1 DISTRICT KANKER

DISTRICT PROFILE Name of the district—Kanker State-- Chhattisgarh 1. Demographic profile (Based on 2010 report) Population 650934 (CENSUS 2001) Rural 619549 Urban 31385 Population density 100 SC 27663 ST 365031 % of BPL population Others 316355 Literacy rate 73%

2. Administrative profile (RHS 2010) No. of Blocks 07 No. of villages 1082 No. of Gram Panchayats 389

3. Health profile CBR 20.62 Still births per 1000 live births .52 Sex Ratio at birth 1006 Sex Ratio ( 0-6) 974

4. Facility status (2010-11 HMIS / as per district record) MCH -I MCH -II MCH -III SN Public Sector Total No I F I F I F 1 District Hospitals 1 0 0 0 0 1 1 2 Sub Divisional Hospitals 1 0 0 0 01 1 0 3 Other Hospitals ( please specify category/ 0 0 00 0 0 0 type of facility e.g. Referral Hospital, Women and Child Hospital etc. make separate row for each category) 4 CHC 8 0 0 6 6 2 2 5 Block PHCs 6 PHC ( break up to be included if 24*7 31 4 0 25 25 0 0 PHC, Mini PHCs APHC,UGPHC) 7 Total Sub centres 245 146 146 0 0 0 0 8 Total number of functional newborn care units in the district (SNCU, NBSU, NBCC) 9 Number of facilities with Nutritional 3 0 0 0 0 3 1 Rehabilitation Centres (or its equivalent) 10 No. of licensed blood banks (include pvt) 1 0 1 11 No. of licensed blood storage units/centers 1 3 1

*I; Identified, F: Functional

5. Facilities in district and service delivery (1 April 11 to Oct 11) No. of normal No. of new Facilities Total No. C-section FP services delivery born admitted MCH-I 146 1116 0 0 MCH-II 31 1813 0 1050 MCH-III 3 1778 4 834

6. Accreditation of Private Health Facilities: SN Private Sector Accreditate Accreditate Accreditate Accreditated d for d for d for MTP for any other Normal Normal services Delivery Delivery & LSCS 1 No of Private Hospitals accreditated 3 3 0 2 under JSY 2 No of Private Hospitals accreditated 3 0 under any other scheme

7. Maternal Health: 2011-12 (HMIS) 2010-11 1st Quarter 2nd Quarter 3rd 4th Indicators (HMIS) Quarter Quarter No. (%) No. (%) No. (%) No. (%) No. (%) Estimated pregnancies 16085 17787 Expected deliveries 16085 17787 Total ANC registrations (Against 16762 104.2 4918 27.64 4785 26.90 estimated preg) Registrations within 12 weeks, 10047 62.46 2421 13.61 2591 14.56 (Against estimated preg) Three ANC checkups (Against estimated 13452 84.19 3902 21.93 3886 21.84 preg) 100 IFA tablets given (Against estimated 14684 91.29 4181 23.50 4827 27.13 preg) Hypertensive cases detected (Against 133 .82 177 .99 152 .85 estimated preg) Women having Hb less than 11 gms 4040 25.11 2408 13.53 2284 12.84 (Against estimated preg) Women treated for severe anaemia 292 1.81 42 .23 21 .11 (Hb<7) (Against estimated preg) Total no. Institutional deliveries 9146 56.86 2099 11.80 2484 13.96 (Against expected deliveries)  Public (Against expected 7157 44.49 1735 9.75 2085 11.72 deliveries)  Private(Against expected 1989 12.36 364 2.04 399 2.24 deliveries) Total no. home deliveries (Against 5654 35.15 1208 6.79 1356 7.62 expected deliveries) Unreported deliveries (Against expected 1285 7.98 - - deliveries) Total C section deliveries (Against 217 2.34 71 3.38 60 2.41 institutional deliveries)  Public(Against institutional 4 .04 2 .11 3 .14 deliveries)

 Private(Against institutional 213 2.32 69 3.97 57 2.73 deliveries) Total complicated cases managed. 1142 7.71 177 5.35 352 9.16 (Against total reported deliveries) Total Live births against estimated 14522 90.28 3557 19.99 3440 19.33 pregnancies Contd.

2011-12 (HMIS) 2010-11 1st Quarter 2nd Quarter 3rd 4th Indicators (HMIS) Quarter Quarter No. (%) No. (%) No. (%) No. (%) No. (%) PNC within 48 hours of delivery. (Against 7518 2677 80.94 2392 62.29 total reported deliveries) Stay ( in facility) for more than 48 hours 1011 11.05 87 159 after delivery (Against institutional deliveries) Total abortions (Against estimated 239 1.48 66 92 pregnancies)  MTP less than 12 weeks 45 4 27

 MTP more than 12 weeks 11 1 2

JSY beneficiaries Total no. of JSY beneficiaries 7791 1910 2287

No. of JSY beneficiaries paid within 24 7791 1910 2287 hours fm JSY Register (Against total JSY beneficiaries) No. of JSY beneficiaries paid post 24 hours fm JSY Register (Against total JSY beneficiaries)

8. Pregnancy Tracking: No. of pregnant women data entered in software (under No: 8530 % 53.44 name based information tracking system against estimated pregnancies) Time line for achieving the data entry in software 50% to 75% 75% to 100% (month & year) dd/mm/yy dd/mm/yy

9. Maternal Death Review: Indicators 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter No. of maternal deaths reported (Community & Facilities) 2 4 No. of deaths reviewed  No. due to PPH  No. due to Eclampsia  No. due to Sepsis  No. due to Obstructed labor  No. due to Referral delays  No due to severe anaemia  No. due to Other causes 2 4

10. Child Health: 2011-12 (HMIS) 2010-11 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Indicators (HMIS) Target Actual Target Actual Target Actual Target Actual Target Actual New born breastfed 14522 12710 No. - 3279 3177 within one hr of birth (against live births) % - Number of new 14522 3280 No. - 410 357 born weighed less than 2.5 kgs % - (against live births) No of diarrhoea & 6778 538 781 dehydration cases No of respiratory 3444 73 154 infection cases admitted No of functional ------NICU (medical college) No of functional 0 0 1 0 SNCU (DH/MCH III) No of functional 0 0 10 0 NBSU (FRU/CHC/MCH II) No. of children admitted to NBSU No. of referrals No. of functional NBCCs (all levels)

11. Child Tracking: No. of children data entered in software (under name based No:6899 % 47.54 information tracking system against live births) Time line for achieving the data entry in software 50% to 75% 75% to 100% (month & year) dd/mm/yy dd/mm/yy

12. Infant and Child Death Review Sl Infant and Child Death Review 1st 2nd 3rd 4th no Quarter Quarter Quarter Quarter 1 Infant Deaths within 24 hrs of birth 38 28 2 Infant Deaths between 24hrs & under 1 week 81 92 3 Infant Deaths between 1 week & under 1 month (causes of death below one month and for children up to 5 years is entirely different and cannot be clubbed )  No. due to Sepsis  No. due to asphyxia

 No. due to LBW Sl Infant and Child Death Review 1st 2nd 3rd 4th no Quarter Quarter Quarter Quarter  No. due to preterm birth  Other causes 4 Child Deaths between 1yr under 5years 48 32 5 Total Infant & Child deaths  No due to Pneumonia/ARI  No due to diarrhoea /dehydration  No due to fever ( to be deleted- fever cannot be the cause of death, this classification has to match international classification)  No due to measles  No due to Referral delays  No. due to Other causes 48 32 Note:- *This data will be maintained at MoHFW

13. Immunization:

A. Indicators 2011-12 (HMIS) Indicators 2010-11 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter (HMIS) No of fully immunized 13556 2941 3679 children (against live %- 93.34 births)

B. Outreach services: Outreach services 1st Quarter 2nd Quarter 3rd 4th Quarter Quarter No. of Immunization sessions planned 3296 3151 No. of Immunization sessions held 3026 3062 No. of VHNDs planned No. of VHNDs held 3098 3501

14. Family Planning: 2011-12 (HMIS) Indicators 2010-11 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter (HMIS) No. of eligible couple (estimated) 12158 Eligible couples with unmet need 15267 Total reported FP users 22980 4881 9518 Limiting methods (sterilizations) 4350 157 1727 Spacing methods 18630 4724 7791  IUD 3872 699 1927  Condoms 9504 2935 3016  OCPs 5254 1090 2848

15. Community Processes: 2011-12 (HMIS) Indicators 2010-11 from 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter district record Total No. of ASHAs in place 2776 2776 2776

No. of ASHAs trained in:  Module five 2776 2776 2776  Module six 2276 2776 2776  Module seven 2776 2776 2776

16. Program Management Unit: A. Regular Technical Resource:

Human Resource- No. No. No of field visits No. of Corrective Action taken District technical Sanction In undertaken in Tour officers ed positio last quarter report n submitte d CMO 1 1 45 45 RCHO 1 1 ACMO 1 0 DMO 1 1 DTO 1 1 DIO 1 1 DLO 1 1 Other (specify)

B. Other Managerial Resource:

Indicators No. No. No of field No. of Tour Corrective Action taken Sanctioned In visits report position undertaken in submitted last quarter DPM 1 1 23 DAM 1 1 3 DPC M&E Officer BPM 7 1 BAM 7 2 Block Data Manager RPM RMA 63 R M&E

17. Deployment and Performance of Human Resources under NRHM: Human Sanctd. No. No. Specify How Performance Indicators(April, 2010 to Resource In trained training many March 2011) positio deployed N.D C.S Tubectom Vasectom IUD n at y y functional facilities Obs/Gyne 0 0 0 0 0 Peads 0 0 0 0 0 Anesth 0 0 0 0 0 Others(Spl.) 0 0 0 0 0 MO(Allopathic )

MO(AYUSH) ANM 59 13 0 0 13 SN 28 18 3 SBA,NS 15 SK LT

18. Deployment of Contractual Manpower (Facility-Wise) under NRHM: Name of Type of No of Posted Physical Achievement(April, 2010 to March 2011) the Facility contractual from Facility (APHC/PH manpower C/ MO- FRU/DH) SN ANM LT N.D C.S No. of No. of Tube Vasectomy IUDs 3 fully ctomy ANCs immu. children MO- SN ANM LT MO- SN ANM LT MO- State 365 400 121 SN-18 ANM-13 LT

Note: - Right now this type of data is not available but we have made formats for this and we will send it further in coming week.

19. Monitoring Mechanism: Monthly meetings in the last quarter Number Periodicity Type of personnel attended the meeting Monthly meetings At PHC Level 1344 Weekly ANM,LHV,Supervisiors Monthly meetings At Block level 49 Monthly ANM Supervisiors SN,BEE ,BMO Monthly meetings At District Level under DM 4 Quarter Programme officer,DPM,CMHO Monitoring Meetings at District Level under 7 Monthly BEE,BMO,DPO,CMHO CMO Sectoral Meetings for convergence 12 Monthly DPM CMHO LHV/DPHN/BEE and other health supervisor

20. Systemic Issues: Sl Issues District Mechanism Whether Free no 1 Referral transport PHC to CHC, CHC to DH, DH to Medical College Yes

Raipur

2 Biomedical waste Deep Pit in Every Health Instittute management 3 Drug Procurement Central purchasing (State Activity) 4 Equipment Minor Maintence of Equipment By jeevan Deep Maintenance samities and major maintance of equipments is state subject 5. Diet Diet provided to inpatient by health institute itself Yes

21. ARSH a. No. of ARSH Clinics established and functional: Established: NIL, Functional: NIL

22. SCHOOL HEALTH PROGRAMME a. No. of schools identified in the district :2428

b. No. of Schools covered :2428

c. No. of girls and boys covered : 67091

d. Periodicity : Monthly

23. PNDT a. Whether District Appropriate Authority is formed: Yes

b. Periodicity: Quarterly

Name ofthe State/ UT/Distt :U.B.Kanker

Infrastructure Upgradation A. Overview of Health Infrastructure and achievements in the Mission - High Focus Districts Required Number of facilities Number of facilties functional Number of Total no. of as per functional in 2005 (i.e. at the as of 30th September 2011 new facilities facilities which population start of Mission) under will be norms construction functional at the (census end of the 2001) Mission period Health Gov Rented No. functi- Govt. Rented No. Facility t. building oning in building buildin functi- buil other bldgs g oning in ding without other paying bldgs rent* without paying rent* 1 2 3 4 1+2+3+4 1 1 0 0 1 0 0 0 1 District Hospitals (DH) Sub- 1 1 0 0 1 0 0 0 1 Divisional Hospitals and other hospitals above CHC CHCs 8 8 0 0 8 0 0 0 8 PHCs 28 13 1 14 27 0 4 0 31 Other Health facilities above SC but below block level (may include APHC etc.) Sub- 217 91 0 113 123 0 74 48 245 Centres * Facilities functional in other buildings like Panchayat buildings/ voluntary/ social organization, etc.

A. 2 Status of Block-wise Availability of Health Facilities (Information to be collected only at District Level) Name of District: Disrtict U Bastar Kanker No. of Health facilities above SC No. of Sub- but below Divisional block level Hospitals and No. of other than other hospitals District No. of PHCs (may above CHC level Sr. Subce include No. of No. of but below hospitals No Name of Block Population ntres APHC etc.) PHCs CHCs District Level if any 1 Dhanelikanhar 116336 37 0 4 1 0 1 2 Narharpur 114124 37 0 4 2 0 0 3 Charama 110157 33 0 6 1 0 0 4 Bhanupratappur 98829 33 0 4 1 0 0 5 Durgukondal 67942 25 0 4 1 0 0 6 Antagarh 74348 33 0 3 1 0 0 7 Koilibeda 161259 47 0 6 1 1 0

B. Information on Progress of New Constructions taken up under NRHM in the State (cumulative till 30th September 2011) Health New Construction Progress of New Constructions Remarks/ Facility sanctioned under Shortcomings NRHM so far

Completed Under Sanctioned but Yet Construction to start

High Non High Non High Non High Non Focus High Focus High Focus High Focus High District Focus District Focus District Focus District Focus s District s District s District s District s s s s District 0 0 0 0 Hospitals (DH)

Sub- 0 0 0 0 Divisiona l Hospitals and other hospitals above CHC CHCs 0 0 0 0 PHCs 0 0 0 0 Other Health facilities above SC but below block level (may include APHC etc.)

Sub- 22 0 21 1 Centres

C. Information on Progress of Upgradation of Health Facilities under NRHM in the State (cumulative till September 2011) Health Facility Upgradation Progress Remarks/ sanctioned under Shortcomin NRHM so far gs

Completed Under Sanctioned but Yet Construction to start

High Non High Non High Non High Non Focus High Focus High Focus High Focus High Focus Focus Focus Focus

District Hospitals 0 0 0 0 0 0 0 0 (DH)

Sub-Divisional 0 0 0 0 0 0 0 0 Hospitals and other hospitals above CHC CHCs 6 0 6 0 0 0 0 0 PHCs 3 0 3 0 0 0 00 0 Other Health 0 0 0 0 0 0 0 0 facilities above SC but below block level (may include APHC etc.)

Sub-Centres 32 32 0 0 0 0

D. Status of Accommodation for Health Care Providers: Facility Availability and Shortage of Staff Quarters at all faciltiies Type

Doctors/ Specialists Nurses and Paramedics Other staff

Required Available Added Required Available Added Required Available Added (Sept (Sept 2011) during (Sept (Sept during (Sept (Sept during 2011) Mission 2011) 2011) Mission 2011) 2011) Mission period period period

District 28 7 7 26 0 0 32 0 0 Hospitals (DH)

Sub- 6 4 0 15 6 0 20 4 0 Divisional Hospitals and other hospitals above CHC CHCs 58 27 0 163 49 0 122 41 0 PHCs 54 54 0 108 54 0 108 54 0 Other Health 0 0 0 0 0 0 0 0 0 facilities above SC but below block level (may include APHC etc.) Sub-Centres 0 0 0 0 0 0 254 118 44

Name of the State/ UT: District Kanker E. Sources of Funds for Health Care Infrastructure: 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 NRHM 17.50 305.56 Other 181.4 105 Central (EUSSP) (EUSSP) Ministry Funds

State Budget

Donor funds

Financial Commission Grants

Other sources

Total

F. Information on ASHA Districts Number of Number Number of Number Number of ASHA trained up to Number ASHA of ASHA ASHAs of ASHAs following Modules till date of required Selected dropped in place ASHAs out with drug kits

5th 6th 7th

1 2776 2776 0 2776 2776 2776 2776 2776

G. Mother and Child Tracking System Sub- Other Health PHCs Other than CHCs Area DHs centres facilities CHC at or Hospitals above SC but above block / below block level but General level below Hospitals District Level No. of Data Entry Points 0 0 2 1 7 0 0 No. of facilities reporting on 204 0 0 0 0 0 0 MCTS portal

No. of facilities where DEOs 0 0 27 0 7 1 are deployed for data entry

No. of facilities where 204 0 28 1 7 0 0 ANMs/ DEOs are trained for data capturing on MCTS formats and uploading on MCTS portal No. of facilities where 21 1 8 0 1 computers with internet connectivity available

No. of faciltiies using CSC 0 0 0 0 0 0 0 (Common Service Centre) SWAN centes for data entry on MCTS portal

No. of facilities generating 204 0 28 1 8 0 0 and using work-plan of MCTS No. of facilities doing 204 0 28 1 7 0 0 verification of data to reduce errors and anomalies occurred at the time of data capturing and entry

H. Information on Programme Management Units

Level No. of Regular No. of contractual Staff in No. of contractual support Total Number Staff important positions like staff such as programme of Staff in Programme managers and assistants/ DEOs/ typists/ SPMU Consultants who have been peons employed for their technical expertise

SPMU

DPMU 0 01DPM,01DAM,01 03 DEO (CMHO) ,01 DDO,1DAA,00DDA DEO (DH) 8 BPMU 0 01 BPM,02 BADA 27 PADA ,7 DEO 37 Total

I. Information on Delivery Points

S.No Indicator Number

1 Total No. of SCs 245

a No. of SCs conducting >3 deliveries/month 20

2 Total No. of 24X7 PHCs 12 a No. of 24X7 PHCs conducting > 10 deliveries /month 4 3 Total No. of any other PHCs 18 a No. of any other PHCs conducting > 10 deliveries/ month 1 4 Total No. of CHCs ( Non- FRU) 6 a No. of CHCs ( Non- FRU) conducting > 10 deliveries /month 4 5 Total No. of CHCs ( FRU) 2 a No. of CHCs (FRU) conducting > 20 deliveries /month 2 b No. of CHCs (FRU) conducting C-sections 0 6 Total No. of any other FRUs (excluding CHC-FRUs) 2 a No. of any other FRUs (excluding CHC-FRUs) conducting > 20 deliveries 2 /month

b No. of any other FRUs (excluding CHC-FRUs) conducting C-sections 0

7 Total No. of DH 1 a No. of DH conducting > 50 deliveries /month 1 b No. of DH conducting C-section 1 8 Total No. of District Women And Children hospital (if separate from 0 DH)

a No. of District Women And Children hospital (if separate from DH) 0 conducting > 50 deliveries /month

b No. of District Women And Children hospital (if separate from DH) 0 conducting C-section

9 Total No. of Medical colleges 0 a No. of Medical colleges conducting > 50 deliveries per month 0 b No. of Medical colleges conducting C-section 0 10 Total No. of Accredited PHF 3 a No. of Accredited PHF conducting > 10 deliveries per month 2 b No. of Accredited PHF conducting C-sections 2

N. Other Indicators A Infrastructure As on 01.04.2005 As on 31.03.2011 1 Blood Storage Units 1 2 2 Blood Banks 1 1 3 SNCUs 0 01 (Not Functional) 4 NBSU 0 02 5 NBCC 0 10 6 Total Number of Beds 7 Bed population Ratio (No. of beds per thousand population) 8 Number of Facilities functioning as As on 01.04.2005 As on 31.03.2011 per IPHS Total No of Functioning Total No Functioning Facilities as per IPHS of as per IPHS Facilities DH 1 1 CHC 8 8 PHC 28 31 Sub centre 204 245 B Utilization of United Grants No. of facilities having Total No. of Facilities more than 50 % utilization receiving grants in 2010-11 in 2010-11 Utilization of RKS Grants 5 37 Utilization of United Funds 0 239 Utilization of Annual Maintainance Grants 0 101 Amount of funds spent on Total Expenditure under NGOs/ PPPs cumulative NRHM cumulative till till 2010-11 2010-11 C PPP /NGOs D Total Annual OPD in the Percentage increase over District/ State previous year 2005-06 441117 2006-07 443476 2007-08 482364 2008-09 436573 2009-10 437137 2010-11 383784 E Lab Services 1.04.2005 31.03.2011 No of patients tested for any ailment in labs at the PHCs No of patients tested for any ailment in the labs at CHCs % of 24x7 facilities where 24X7 lab services are available

ANNEXURE-II DISTRICT KAWARDHA

DISTRICT PROFILE : KABIRDHAM Name of the district Kabirdham 1. Demographic profile (Based on 2010 report) Population 822239 (CENSUS 2011) Rural 734894 Urban 87345 Population density 138 (CENSUS 2001), 195 (CENSUS 2011) SC 74351 ST 121957 % of BPL population Others Literacy rate 61.95

2. Administrative profile (RHS 2010) No. of Blocks 02 No. of villages 1004(Populated Village-953) Census 2001 No. of Gram Panchayats 367

3. Health profile CBR 30 Census-2011 Still births per 1000 live births 198 Still Birth, 11327 Live Birth Sex Ratio at birth 1002(Census 2001), 997(Census-2011) Sex Ratio ( 0-6) 1028(M-71348, F-69404) Census 2011

4. Facility status (2010-11 HMIS / as per district record) MCH -I MCH -II MCH -III SN Public Sector Total No I F I F I F 1 District Hospitals 01 - - - - 1 0 2 Sub Divisional Hospitals - 3 Other Hospitals ( please specify - category/ type of facility e.g. Referral Hospital, Women and Child Hospital etc. make separate row for each category) 4 CHC 05 01 0 02 04 02 0 5 Block PHCs - 6 PHC ( break up to be included if 24*7 23 11 19 12 04 - - PHC, Mini PHCs APHC,UGPHC) 7 Total Sub centres 144 75 62 8 Total number of functional newborn 12(01- 0 0 10 0 02 01 care units in the district (SNCU, NBSU, SNCU, NBCC) 01-NBSU, 10- NBCC) 9 Number of facilities with Nutritional 01 01 01 Rehabilitation Centres (or its equivalent) 10 No. of licensed blood banks (include 01 01 01 pvt)

11 No. of licensed blood storage - - - units/centers *I; Identified, F: Functional

5. Facilities in district and service delivery No. of normal No. of new Facilities Total No. C-section FP services delivery born admitted MCH-I 87 MCH-II 13 324 MCH-III 03 504 0 512

6. Accreditation of Private Health Facilities: SN Private Sector Accreditated Accreditated Accreditated Accreditated for Normal for Normal for MTP for any other Delivery Delivery & services LSCS 1 No of Private Hospitals accreditated 02` 02 - - under JSY 2 No of Private Hospitals accreditated - - - - under any other scheme

7. Maternal Health: 2011-12 (HMIS) 2010-11 (HMIS) 1st Quarter 2nd Quarter 3rd 4th Indicators Quarter Quarter No. (%) No. (%) No. (%) No. No. (%) (%) Estimated pregnancies 19754 6748 6748 (27135/4) (27135/4) Expected deliveries 17958 6167 6167 (24668/4) (24668/4) Total ANC registrations 21990 111.32% 6155 90.73% 6134 90.42% (Against estimated preg) Registrations within 12 5885 29.79% 1961 28.91% 1930 28.45% weeks, (Against estimated preg) Three ANC checkups 17624 89.22% 4375 64.49% 4915 72.45% (Against estimated preg) 100 IFA tablets given 20536 103.96% 4268 62.92% 3281 48.37% (Against estimated preg) Hypertensive cases detected 0.00% 0.00% 0.00% (Against estimated preg) Women having Hb less 6526 33.04% 1703 25.10% 1819 26.81% than 11 gms (Against estimated preg) Women treated for severe 3 0.02% 2 0.03% 4 0.06% anaemia (Hb<7) (Against estimated preg) Total no. Institutional 7234 40.28% 1721 27.91% 2328 37.75% deliveries

(Against expected deliveries)  Public (Against 6587 36.68% 1545 25.05% 2103 34.10% expected deliveries)  Private(Against 647 3.60% 176 2.85% 225 3.65% expected deliveries) Total no. home deliveries 14202 80% 2558 41.48% 3189 51.71% (Against expected deliveries) Unreported deliveries - - - (Against expected deliveries) Total C section deliveries - (Against institutional deliveries)  Public(Against - - - institutional deliveries)  Private(Against - 58 4% 67 3% institutional deliveries) Total complicated cases 58 4% 67 3% managed. (Against total reported deliveries) Total Live births against 21190 4654 69% 5775 86% estimated pregnancies Contd.

2011-12 (HMIS) 2010-11 1st Quarter 2nd 3rd 4th Indicators (HMIS) Quarter Quarter Quarter No. (%) No. No. No. No. (%) (%) (%) (%) PNC within 48 hours of delivery. 4467 2375 2808 (Against total reported deliveries) Stay ( in facility) for more than 48 hours 1489 2230 after delivery (Against institutional deliveries) Total abortions (Against estimated 70 89 pregnancies)  MTP less than 12 weeks

 MTP more than 12 weeks

JSY beneficiaries Total no. of JSY beneficiaries 9897 1996 2573

No. of JSY beneficiaries paid within 24 hours fm JSY Register (Against total JSY beneficiaries) No. of JSY beneficiaries paid post 24 hours fm JSY Register (Against total JSY beneficiaries)

8. Pregnancy Tracking: No. of pregnant women data entered in software (under No: % name based information tracking system against estimated pregnancies) Time line for achieving the data entry in software 50% to 75% 75% to 100% (month & year) Nill(<50%)

9. Maternal Death Review: Indicators 1st 2nd 3rd 4th Quarter Quarter Quarter Quarter No. of maternal deaths reported (Community & 2 17 - - Facilities) No. of deaths reviewed (audited by Block) 2 17 - -  No. due to PPH  No. due to Eclampsia  No. due to Sepsis  No. due to Obstructed labor  No. due to Referral delays  No due to severe anaemia  No. due to Other causes

10. Child Health: 2011-12 (HMIS) 2010-11 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Indicators (HMIS) Targe Actua Targe Actua Targe Actua Targe Actua Targe Actua t l t l t l t l t l New born 21190 18062 No. - 4276 5775 5526 breastfed within 4654 one hr of birth (against live % - 92% 96% births) Number of new 1823 No. - 215 363 born weighed less than 2.5 kgs % - 5% 7% (against live births) No of diarrhea & 17958 13716 2396 3437 dehydration cases No of respiratory 17958 21192 3435 4845 infection cases admitted No of functional - - NICU (medical college) No of functional 01 SNCU (DH/MCH III) No of functional NBSU (FRU/CHC/MC H II)

No. of children admitted to NBSU No. of referrals No. of functional - - NBCCs (all levels)

11. Child Tracking: No. of children data entered in software (under name No: % based information tracking system against live births) Time line for achieving the data entry in software 50% to 75% 75% to 100% (month & year) dd/mm/yy dd/mm/yy

12. Infant and Child Death Review: Sl Infant and Child Death Review 1st 2nd 3rd 4th no Quarter Quarter Quarter Quarter 1 Infant Deaths within 24 hrs of birth - - - - 2 Infant Deaths between 24hrs & under 1 week 56 72 3 Infant Deaths between 1 week & under 1 month (causes of 18 49 death below one month and for children up to 5 years is entirely different and cannot be clubbed )  No. due to Sepsis  No. due to asphyxia  No. due to LBW Sl Infant and Child Death Review 1st 2nd 3rd 4th no Quarter Quarter Quarter Quarter  No. due to preterm birth  Other causes 4 Child Deaths between 1yr under 5years 16 39 5 Total Infant & Child deaths  No due to Pneumonia/ARI  No due to diarrhoea /dehydration  No due to fever ( to be deleted- fever cannot be the cause of death, this classification has to match international classification)  No due to measles  No due to Referral delays  No. due to Other causes Note:- *This data will be maintained at MoHFW

13. Immunization:

A. Indicators 2011-12 (HMIS) Indicators 2010-11 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter (HMIS) No of fully immunized 18454 3911 5429 children (against live %- births)

B. Outreach services: Outreach services 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter No. of Immunization sessions planned 2544 2474 No. of Immunization sessions held 2183 1528 No. of VHNDs planned No. of VHNDs held

14. Family Planning: 2011-12 (HMIS) according Routine Report Indicators 2010-11 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter (HMIS) No. of eligible couple 8500 Target (estimated) Eligible couples with unmet need Total reported FP users 5660 94 428 Limiting methods (sterilizations) Spacing methods  IUD 2274 153 909  Condoms 5348 332 876  OCPs 5340 578 630

15. Community Processes: 2011-12 (HMIS) Indicators 2010-11 from 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter district record Total No. of ASHAs in 1702 place No. of ASHAs trained in:  Module five 1633 1633 1633  Module six 1633 1633 1633  Module seven 1633 1633 1633 16. Program Management Unit:

A. Regular Technical Resource: Human Resource- No. No. No of field visits No. of Corrective Action taken District technical Sanctioned In undertaken in Tour officers position last quarter report submitted CMO 01 01 0 0 RCHO 01 01(ic/) ACMO DMO 01 01(i/c) DTO 01 01(i/c) DIO 01 01(i/c) DLO 01 01(i/c) Other (specify)

B. Other Managerial Resource: Indicators No. No. No of field No. of Corrective Action taken Sanctioned In visits Tour position undertaken in report 74

last quarter submitted DPM 01 01 17 13 DAM 01 01 NA NA DPC - - NA NA M&E Officer 01 01 NA NA (District Data Officer) BPM 04 00 NA NA BAM 04 01 NA NA Block Data 04 02 NA NA Manager (DEO) RPM NA NA RAM 23 20 NA NA (PADA) R M&E - - NA NA

17. Deployment and Performance of Human Resources under NRHM: Human Sanctd. No. No. Specify How Performance Indicators(April, 2010 to March Resource In trained training many 2011) positio deployed N.D C.S Tubectom Vasectom IUD n at y y functional facilities Obs/Gyne ------Peads ------Anesth ------Others(Spl.) ------MO(Allopathic ------) MO(AYUSH) ------ANM - 21 16 SBA Training SN - 11 - NSKK LT - - -

18. Deployment of Contractual Manpower (Facility-Wise) under NRHM: Name of Type of No of Posted Physical Achievement(April, 2010 to March 2011) the Facility contractual from Facility (APHC/P manpower HC/ MO- FRU/DH) SN ANM LT N.D C. No. No. of Tube Vasectom IUDs S of 3 fully ctom y ANC immu. y s children CHC MO-00 SN-05 2011 ANM- 2011 LT-00 PHC MO-00 SN-06 2009 ANM-00 - LT-00 Sub Center MO-00 SN-00 ANM-20 2010 LT-.00

Note :- Right now this type of data is not available but we have made formats for this and we will send it further in coming week. 19. Monitoring Mechanism: Monthly meetings in the last quarter Number Periodicity Type of personnel attended the meeting Monthly meetings At PHC Level Monthly meetings At Block level Monthly meetings At District Level under DM Monitoring Meetings at District Level under CMO Sectoral Meetings for convergence LHV/DPHN/BEE and other health supervisor

20. Systemic Issues: Sl Issues District Mechanism Whether Free no 1 Referral transport 16(12 Govt Vehicle, 04-108 Sanjeewani Express)

2 Biomedical waste 04 Block management 3 Drug Procurement Not in District Level

4 Equipment Maintenance 5. Diet 05(01 DH, 04 CHC)

21. ARSH a. No. of ARSH Clinics established and functional: Established: Nil, Functional:Nil

22. SCHOOL HEALTH PROGRAMME a. No. of schools identified in the district : 1823

b. No. of Schools covered :1375

c. No. of girls and boys covered:115015 (Total)

d. Periodicity : July-October 2011 Report

23. PNDT a. Whether District Appropriate Authority is formed: Yes

b. No. of District Appropriate Authority meetings held : NA

c. Periodicity: NA

Name of the State/ UT: Chhattisgarh

A. Status of Block-wise Availability of Health Facilities Name of District: Kawardha No. of Health No. of Sub- facilities above Divisional No. of SC but below Populatio Hospitals and District Sr. Name of No. of block level No. of No. of n (Census- other hospitals level No Block Subcentres other than PHCs CHCs 2011) above CHC but hospitals PHCs (may below District if any include APHC Level etc.) 1 Kawardha 156424 33 - 3 1 - 01 2 Bodla 138756 46 - 6 02 - - 3 S Lohara 107597 24 - 5 1 - - 4 Pandariya 181775 41 9 1 - -

584552 144 23 05 - -

INFRASTRUCTURE UPGRADATION SUB‐CENTRES Kawardha District Total No. of Sub Centers functioning 144 No. of Sub Centers functioning without ANMs 33 No. of Sub Centers with ANM quarters 111 No. of Sub Centers without regular water supply 33 No. of Sub Centers without electric supply 111 Primary Health Centers Total No of PHCs functioning 15 No. of PHCs functioning without a Doctor 09 No. of PHCs functioning without lab.technician 21 No. of PHCs functioning without Pharmacist No. of PHCs functioning without Nurse Midwife/ Staff Nurse 17 No.of PHCs functioning without ANMs Total No of PHCs functioning without ANM No. of PHCs functioning without a Doctor No. of PHCs having two doctors including AYUSH practitioner 0 No.of PHCs with labor room 0 No. of PHCs with O. T. 0 No. of PHCs with 4 – 6 beds 15 No. of PHCs without electricity 14 No. of PHCs without regular water supply 15 No. of PHCs with labor room 13 No. of PHCs without electricity 01 No. of PHCs without regular water supply 0 No. of PHCs with telephone facility 0 No. of PHC without all weather motorable approach road. 0 No. of PHCs with labor room 15

No. of PHCs having Doctor‟s quarter 8 No. of PHCs having a vehicle 3 Community Health Centres No. of CHCs with functional Laboratory, OT, Labour room, X ray 4 Number of CHCs with 30 beds 3 Number of CHCs having quarters for specialist Doctors 1 (other 3 under cons.) Number of CHCs presently operating in PHC building 0 First Referral Units No. of FRU‟s with functional O.T, labor Room, X Ray, Lab 2 No. of FRU‟s with Blood storage/linkage facility 2(under cons.) No. of FRU‟s having referral transport service 2 No. of FRU‟s with back‐up generator/electric supply 2 No. of FRU‟s without residential quarters for essential staff 2(under cons.)

B. Total functional delivery points in Public Health Facilities of the States/UT State/UT. Chhattisgarh, District: Kabirdham

S.No Indicator Number

1 Total No. of SCs 144 a No. of SCs conducting >3 deliveries/month 62

2 Total No. of 24X7 PHCs 10 a No. of 24X7 PHCs conducting > 10 deliveries /month 03

3 Total No. of any other PHCs 12 a No. of any other PHCs conducting > 10 deliveries/ month 01

4 Total No. of CHCs ( Non- FRU) 02 a No. of CHCs ( Non- FRU) conducting > 10 deliveries /month 01

5 Total No. of CHCs ( FRU) 02 a No. of CHCs (FRU) conducting > 20 deliveries /month 02 b No. of CHCs (FRU) conducting C-sections Nil

6 Total No. of any other FRUs (excluding CHC-FRUs) Nil a No. of any other FRUs (excluding CHC-FRUs) conducting > 20 Nil deliveries /month b No. of any other FRUs (excluding CHC-FRUs) conducting C-sections Nil

S.No Indicator Number

7 Total No. of DH 01 a No. of DH conducting > 50 deliveries /month 00 b No. of DH conducting C-section 00

8 Total No. of District Women And Children hospital (if separate from Nil DH) a No. of District Women And Children hospital (if separate from DH) Nil conducting > 50 deliveries /month b No. of District Women And Children hospital (if separate from DH) Nil conducting C-section

9 Total No. of Medical colleges Nil a No. of Medical colleges conducting > 50 deliveries per month Nil b No. of Medical colleges conducting C-section Nil

10 Total No. of Accredited PHF 02 a No. of Accredited PHF conducting > 10 deliveries per month 01 b No. of Accredited PHF conducting C-sections 02

*Provide the status in a soft copy and upload it on the State/UT NRHM website. *Upload on State/UT NRHM website, the name wise list of the above facilities which are delivery points.

C. Human Resources Kawardha HR status as on date

In Position

Category Sanctioned Contractual Regular NRHM Funds Other Sources 23 Doctors 68 11 Specialists 21 29 Paramedics 31 17 Staff Nurses 34 11

ASHAs 1702 79 MPW 150 121 ANM 169 21 3 Lab Technician 13 29 Pharmacist 31 1 X-Ray Technician 8 32 Ward Staff 37

Personal staff 2 Cleaning Staff 5

State: Chhattisgarh, District: Kawardha D. Training Status of the District Type of Target Target Achievement Achievement No. of trained Performance Training for for cummulative or Nos. MOs posted at (Specify No. NRHM 2011- till March trained in facilities where of deliveries, period 12 2011 2011-12 their skills are No. of (upto (April 11-till being uilised - C.section 2012) date) * eg. FRUs for and No. of LSAS & EmOC/ Spinal MTP; 24X7 Anesthesia, PHCs for MTP, No. of BeMOC/MTP; any other Facilities complications conducting attended) delivery for SBA LSAS 2 1 2 2 No

EmOC 3 0 3 3 No(Certfication ReQuired) BEmOC 0

SBA 176 20 156 16

MTP 8 8 0 0

RTI/STI 22 22 0 0